2016 benefit guide wtxebc - vernon isd
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WEST TEXAS EMPLOYEE BENEFIT COOPERATIVE
EFFECTIVE:
09/01/2016 - 8/31/2017
BENEFIT GUIDE
www.wtxebc.com
1
Benefit Contact Information 3 How to Enroll 4-5 Annual Benefit Enrollment 6-11 1. Benefit Updates 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Annual Enrollment 8 4. Eligibility Requirements 9 5. Helpful Definitions 10 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) 11
TRS-ActiveCare and FirstCare 12-15 APL MEDlink® Medical Supplement 16-19 MDLIVE Telehealth 20-21 Cigna Dental 22-25 Superior Vision 26-27 Aetna Short Term Disability 28-31 Loyal American Cancer 32-35 APL Accident 36-39 UNUM Critical Illness 40-41 UNUM Life and AD&D 42-45 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider 46-49
ID Watchdog Identity Theft 50-51 MASA Medical Transport 52-53 NBS Flexible Spending Account (FSA) 54-57
Table of Contents
HOW TO ENROLL
PG. 4
YOUR BENEFIT UPDATES: WHAT’S NEW
PG. 6
YOUR BENEFITS PACKAGE
PG. 12
FLIP TO...
2
Benefit Contact Information
WTXEBC BENEFITS VISION LIFE AND AD&D
Financial Benefit Services (800) 583-6908 www.wtxebc.com
Group # 28790 Superior Vision (800) 507-3800 www.superiorvision.com
UNUM (866) 679-3054 www.unum.com
MEDICAL DISABILITY FAMILY PROTECTION PLAN
Aetna (800) 222-9205 www.trsactivecareaetna.com
Aetna (800) 872-3862 www.aetna.com
5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com
MEDICAL CANCER IDENTITY THEFT
FirstCare (800) 884-4901 www.firstcare.com/trs
Group # 1600 Loyal American (800) 366-8354
ID Watchdog (800) 970-5182 www.idwatchdog.com
MEDICAL SUPPLEMENT—MEDLINK ® ACCIDENT MEDICAL TRANSPORT
Group # 13634 American Public Life (800) 256-8606 www.ampublic.com
Group # 13634 American Public Life (800) 256-8606 www.ampublic.com
MASA (800) 423-3226 www.masamts.com
TELEHEALTH CRITICAL ILLNESS FLEXIBLE SPENDING ACCOUNT
MDLIVE (888) 365-1663 www.consultmdlive.com
UNUM (866) 679-3054 www.unum.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
DENTAL
Group # 3335915 Cigna (800) 997-1654 www.cigna.com
Benefit Contact Information
3
!
How to Enroll
On Your Device
On Your Computer
Enrollment has just become
easier!
Avoid typing long URLs and scan
directly to your benefits websites,
videos, and benefit guides.
Try it yourself! Scan the following
code in the picture.
Access the WTXEBC benefits
website from your computer, tablet
or smartphone!
Our online benefit enrollment
platform provides a simple and
easy to navigate process. Enroll
at your own pace, whether at
home or at work.
www.wtxebc.com delivers
important benefit information
with 24/7 access, as well as
detailed plan information, rates
and product videos.
SCAN:
4
GO www.wtxebc.com 1
2
Login Steps
3
Go to:
Click Login
Enter Username & Password
OR SCAN
All login credentials have been RESET to the default
described below:
Username:
The first six (6) characters of your last name, followed
by the first letter of your first name, followed by the
last four (4) digits of your Social Security Number.
If you have six (6) or less characters in your last name,
use your full last name, followed by the first letter of
your first name, followed by the last four (4) digits of
your Social Security Number.
Default Password:
Last Name* (lowercase, excluding punctuation)
followed by the last four (4) digits of your Social
Security Number.
Sample Password
l incola1234
l incoln1234
If you have trouble
logging in, click on the
“Login Help Video”
for assistance.
Click on “Enrollment Instructions” for more information about how to enroll.
Sample Username
LOGIN
Open Enrollment Tip
For your User ID: If you have less than six (6) characters in your last
name, use your full last name, followed by the first letter of your first
name, followed by the last four (4) digits of your Social Security Number.
5
Benefit elections will become effective 9/01/2016 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event and changes must be made within 30 days of event.
Online Benefit Access: www.wtxebc.com
You have access to benefit information 24/7 on the employee benefit provided. You can review and print the consolidated enrollment form or benefit guide, download claim forms and website plan summaries, links to carrier websites and provider searches.
Good News! Unum Voluntary Life will allow employees/
spouses to increase existing life insurance coverage all the way up to guarantee issue without evidence of insurability.
MDLIVE Telehealth will have a slight rate increase for
voluntary coverage to $9 per month. This rate will still cover the entire family, employee, spouse and any unmarried children to age 26.
NEW Medical Transportation Solutions will be offered
through MASA. MASA provides medical emergency transportation solutions AND covers your out of pocket medical transport cost when your insurance
falls short. MASA does not use a network which means you are covered anywhere. MASA rates will be $9.00 per month, per employee only/family coverage. Everyone that lives at the same residential address on a fulltime basis is covered on the same membership, as long as they are listed on the membership. Children who are off to an accredited college/university and enrolled fulltime, while working up to a bachelor’s degree, will also be covered as long as their permanent address remains the same as the primary member.
NEW Family Protection –Terminal Illness Plan with
Quality of Life Rider from 5 Star provides a specified death benefit to your beneficiary at the time of death. The Terminal Illness Rider pays 30% of the death benefit directly to you in the event you are diagnosed with a terminal condition that will result in a limited life span of less than 12 months. The Quality of Life Rider provides you with financial protection should you be faced with a chronic medical condition that requires continuous care. This rider accelerates a portion of the death benefit on a monthly basis. This plan is affordable, completely portable as it is an individual policy. Like the name says, this is a Family Protection Plan. You can purchase this plan on your spouse, children, and even grandchildren. Persons under the age of 23 will not have the Quality of Life Rider.
Login and complete your benefit enrollment from 08/01/2016 - 08/22/2016 Enrollment assistance is available by calling Financial Benefit Services at
(866) 914-5202 between 8am – 5pm CST Update your profile information: home address, phone numbers, email, beneficiaries
REQUIRED: Provide correct dependent social security numbers
Benefit Updates - What’s New:
Annual Benefit Enrollment
SUMMARY PAGES
6
CHANGES IN STATUS (CIS):
QUALIFYING EVENTS
Marital Status A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
Change in Number of Tax Dependents
A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.
Change in Status of Employment Affecting
Coverage Eligibility
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.
Gain/Loss of Dependents' Eligibility Status
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent status.
Judgment/Decree/Order
If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.
Eligibility for Government Programs
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
Section 125 Cafeteria Plan Guidelines
SUMMARY PAGES
7
Annual Enrollment
During your annual enrollment period, you have the opportunity
to review, change or continue benefit elections each year.
Changes are not permitted during the plan year (outside of
annual enrollment) unless a Section 125 qualifying event occurs.
Changes, additions or drops may be made only during the
annual enrollment period without a qualifying event.
Employees must review their personal information and verify
that dependents they wish to provide coverage for are
included in the dependent profile. Additionally, you must
notify your employer of any discrepancy in personal and/or
benefit information.
Employees must confirm on each benefit screen (medical,
dental, vision, etc.) that each dependent to be covered is
selected in order to be included in the coverage for that
particular benefit.
New Hire Enrollment
All new hire enrollment elections must be completed in the
online enrollment system within the first 31 days of benefit
eligibility employment. Failure to complete elections during this
timeframe will result in the forfeiture of coverage.
Q&A
Who do I contact with Questions?
For supplemental benefit questions, you can contact your
Benefits/HR department or you can call Financial Benefit Services
at 866-914-5202 for assistance.
Where can I find forms?
For benefit summaries and claim forms, go to the WTXEBC
benefit website: www.wtxebc.com. Click on your school
district, then click on the benefit plan you need information
on (i.e., Dental) and you can find the forms you need under
the Benefits and Forms section.
How can I find a Network Provider?
For benefit summaries and claim forms, go to the WTXEBC
benefit website: www.wtxebc.com. Click on your school
district, then click on the benefit plan you need information
on (i.e., Dental) and you can find provider search links under
the Quick Links section.
When will I receive ID cards?
If the insurance carrier provides ID cards, you can expect to
receive those 3-4 weeks after your effective date. For most
dental and vision plans, you can login to the carrier website
and print a temporary ID card or simply give your provider the
insurance company’s phone number and they can call and
verify your coverage if you do not have an ID card at that
time. If you do not receive your ID card, you can call the
carrier’s customer service number to request another card.
If the insurance carrier provides ID cards, but there are no
changes to the plan, you typically will not receive a new ID
card each year.
SUMMARY PAGES
8
PLAN CARRIER MAXIMUM AGE
Accident American Public Life Through 25
Cancer Loyal American Through 24
Critical Illness UNUM Through 25
Dental Cigna Through 25
Dependent Flex
National Benefit Services
12 or younger or qualified individual unable to care for themselves & claimed
as a dependent on your taxes
Family Protection Plan w/ QOL Rider 5Star Life Issue through 23; Keep to 100
Healthcare FSA National Benefit Services Through 25 or IRS Tax Dependent
Health Savings Account HSA Bank IRS Tax Dependent
Identity Theft ID Watchdog Through 25
Medical Supplement Plan American Public Life Through 25
Telehealth MDLIVE Through 25
Vision Superior Vision Through 25
Voluntary Life and AD&D UNUM Through 25
Employee Eligibility Requirements
Supplemental Benefits: Eligible employees must work 20 or more
regularly scheduled hours each work week.
Eligible employees must be actively at work on the plan effective
date for new benefits to be effective, meaning you are physically
capable of performing the functions of your job on the first day of
work concurrent with the plan effective date. For example, if
your 2016 benefits become effective on September 1, 2016, you
must be actively-at-work on September 1, 2016 to be eligible for
your new benefits.
Dependent Eligibility Requirements
Dependent Eligibility: You can cover eligible dependent
children under a benefit that offers dependent coverage,
provided you participate in the same benefit, through the
maximum age listed below. Dependents cannot be double
covered by married spouses within WTXEBC or as both
employees and dependents.
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.
SUMMARY PAGES
9
Actively at Work You are performing your regular occupation for the employer
on a full-time basis, either at one of the employer’s usual
places of business or at some location to which the employer’s
business requires you to travel. If you will not be actively at
work beginning 9/1/2016 please notify your benefits
administrator.
Annual Enrollment The period during which existing employees are given the
opportunity to enroll in or change their current elections.
Annual Deductible The amount you pay each plan year before the plan begins to
pay covered expenses.
Calendar Year January 1st through December 31st
Co-insurance After any applicable deductible, your share of the cost of a
covered health care service, calculated as a percentage (for
example, 20%) of the allowed amount for the service.
Guaranteed Coverage The amount of coverage you can elect without answering any
medical questions or taking a health exam. Guaranteed
coverage is only available during initial eligibility period.
Actively-at-work and/or pre-existing condition exclusion
provisions do apply, as applicable by carrier.
In-Network Doctors, hospitals, optometrists, dentists and other providers
who have contracted with the plan as a network provider.
Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance
for covered expenses.
Plan Year September 1st through August 31st
Pre-Existing Conditions Applies to any illness, injury or condition for which the
participant has been under the care of a health care provider,
taken prescriptions drugs or is under a health care provider’s
orders to take drugs, or received medical care or services
(including diagnostic and/or consultation services).
Helpful Definitions SUMMARY PAGES
10
Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
Description
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care tax-free.
Employer Eligibility A qualified high deductible health plan. All employers
Contribution Source Employee and/or employer Employee and/or employer
Account Owner Individual Employer
Underlying Insurance Requirement
High deductible health plan None
Minimum Deductible $1,300 single (2016) $2,600 family (2016) N/A
Maximum Contribution $3,350 single (2016) $6,750 family (2016)
Varies per employer
Permissible Use Of Funds
Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).
Not permitted
Year-to-year rollover of account balance?
Yes, will roll over to use for subsequent year’s health coverage.
No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.
Does the account earn interest?
Yes No
Portable? Yes, portable year-to-year and between jobs.
No
HSA vs. FSA SUMMARY PAGES
FOR FSA INFORMATION
FLIP TO… PG. 54
11
2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits*
Type of Service ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health
(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann
Accountable Care Network; Seton Health Alliance)
ActiveCare 2
Deductible (per plan year)
$2,500 employee only $5,000 family
$1,200 individual $3,600 family
$1,000 individual $3,000 family
Out-of-Pocket Maximum (per plan year; does include medical deductible/ any medical copays/coinsurance/any prescription drug deductible and applicable copays/coinsurance)
$6,550 individual $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual)
$6,850 individual $13,700 family
$6,850 individual $13,700 family
Coinsurance Plan pays (up to allowable amount) Participant pays (after deductible)
80% 20%
80% 20%
80% 20%
Office Visit Copay Participant pays
20% after deductible $30 copay for primary $60 copay for specialist
$30 copay for primary $50 copay for specialist
Diagnostic Lab Participant pays
20% after deductible Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility
Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility
Preventive Care See next page for a list of services
Plan pays 100% Plan pays 100% Plan pays 100%
Teladoc® Physician Services $40 consultation fee (applies to deductible and out-of-pocket maximum)
Plan pays 100% Plan pays 100%
High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays
20% after deductible $100 copay plus 20% after deductible $100 copay plus 20% after deductible
Inpatient Hospital (preauthorization required) (facility charges) Participant pays
20% after deductible $150 copay per day plus 20% after deductible ($750 maximum copay per admission)
$150 copay per day plus 20% after deductible($750 maximum copay per admission; $2,250 maximum copay per plan year)
Emergency Room (true emergency use) Participant pays
20% after deductible $150 copay plus 20% after deductible (copay waived if admitted)
$150 copay plus 20% after deductible (copay waived if admitted)
Outpatient Surgery Participant pays
20% after deductible $150 copay per visit plus 20% after deductible
$150 copay per visit plus 20% after deductible
Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays
$5,000 copay plus 20% after deductible
Not covered $5,000 copay (does not apply to out-of-pocket maximum) plus 20% after deductible
Prescription Drugs Drug deductible (per plan year)
Subject to plan year deductible $0 for generic drugs $200 per person for brand-name drugs
$0 for generic drugs $200 per person for brand-name drugs
Retail Short-Term (up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)
20% after deductible
$20 $40** 50% coinsurance**
$20 $40** $65**
Retail Maintenance (after first fill; up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)
20% after deductible
$35 $60** 50% coinsurance**
$35 $60** $90**
Mail Order and Retail-Plus (up to a 90-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)
20% after deductible $45 $105*** 50% coinsurance
$45 $105*** $180***
Specialty Drugs Participant pays
20% after deductible 20% coinsurance per fill $200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply)
A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.
12
TRS-ActiveCare Plans—Preventive Care
Preventive Care Services
Network Benefits When Using In-Network Providers
(Provider must bill services as “preventive care”)
ActiveCare 1-HD ActiveCare Select or ActiveCare Select
Whole Health (Baptist Health System and
HealthTexas Medical Group; Baylor Scott & White Quality Alliance;
Memorial Hermann Accountable Care Network; Seton Health
Alliance)
ActiveCare 2 Network
Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations
Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved.
Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/facts-and-features/fact-sheets/preventive-services-covered-under-aca/#CoveredPreventive ServicesforAdults
For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009).
The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified.
Plan pays 100% (deductible waived; no copay required) Some examples of preventive care frequency and services: Routine physicals – annually age
12 and over Well-child care – unlimited up to
age 12 Well woman exam & pap smear
– annually age 18 and over Mammograms – 1 every year age
35 and over Colonoscopy – 1 every 10 years
age 50 and over Prostate cancer screening – 1 per
year age 50 and over Smoking cessation counseling – 8
visits per 12 months Healthy diet/obesity counseling –
unlimited to age 22; age 22 and over-26 visits per 12 months
Breastfeeding support – 6 lactation counseling visits per 12 months
Plan pays 100% (deductible waived; no copay required) Some examples of preventive care frequency and services: Routine physicals –
annually age 12 and over Well-child care – unlimited
up to age 12 Well woman exam & pap
smear – annually age 18 and over
Mammograms – 1 every year age 35 and over
Colonoscopy – 1 every 10 years age 50 and over
Prostate cancer screening –1 per year age 50 and over
Smoking cessation counseling –8 visits per 12 months
Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months
Breastfeeding support –6 lactation counseling visits per 12 months
Plan pays 100% (deductible waived) Some examples of preventive care frequency and services: Routine physicals – annually
age 12 and over Well-child care – unlimited
up to age 12 Well woman exam & pap
smear – annually age 18 and over
Mammograms – 1 every year age 35 and over
Colonoscopy – 1 every 10 years age 50 and over
Prostate cancer screening – 1 per year age 50 and over
Smoking cessation counseling – 8 visits per 12 months
Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months
Breastfeeding support – 6 lactation counseling visits per 12 months
(Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.
Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark.
To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800-222-9205. The list may change as FDA guidelines are modified.
Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays
After deductible, plan pays 80%; participant pays 20%
$60 copay for specialist $50 copay for specialist
Annual Hearing Examination Participant pays
After deductible, plan pays 80%; participant pays 20%
$30 copay for primary $60 copay for specialist
$30 copay for primary $50 copay for specialist
Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health.
TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.
13
2016-2017 TRS-FirstCare Plan Highlights Plan Summary 2016 -2017
Medical Plan Year Deductible $500 Individual; $1,500 Family
Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) $6,000 Individual: $12,000 Family
Annual Maximum Unlimited
Primary Care Provider (PCP) Office Visit
Includes routine lab/X-ray services, injectables, and supplies
Other services provided in a physician’s office are subject to additional deductibleand copayments/coinsurance
$20 copayment
PCP Office Visit-Dependents, through age 19 $0 copayment
Specialist Office Visit
Includes routine lab/X-ray services
Other services provided in a physician’s office are subject to additional deductibleand copayments/coinsurance
$60 copayment
Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening
No copayment
Surgical Procedures Performed in the Physician's Office 25% copayment1
Minor Emergency/Urgency Care Visit $75 copayment
Emergency Room $500 copayment1
Ambulance Air/Ground
25% copayment1
Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility, behavioral health (mental health/chemical dependency)
25% copayment1
Outpatient Services Facility charges, physician services, surgical procedures, observation unit
25% copayment1
MRI, CT Scan, PET Scan (Facility/Physician) $250 copayment1
Diagnostic Tests Sleep study; Stress test; EKG; Ultrasound; Cardiac imaging; Genetic testing; Non-preventive Colonoscopy (Facility/Physician)
25% copayment1
Home Health Care Limited to 60 visits per plan year 25% copayment1
Hospice Care 25% copayment1
Skilled Nursing Facility Limited to 30 days per plan year 25% copayment1
Accidental Dental Care 25% copayment1
Prosthetics 25% copayment1
Orthotics 25% copayment1
Spinal Manipulation Limited to 10 visits per year 25% copayment1
Durable Medical Equipment 25% copayment1
All Other Covered Services 25% copayment1
14
Prescription Drug Plan Year Deductible $100 Individual: $300 Family
Annual Maximum Unlimited
Participating Retail Pharmacy
Select Generic/ACA (Tier 1) deductible waived
Preferred Generic (Tier 2) deductible waived
Preferred Brand/Non-Preferred Generic (Tier 3)
Non-Preferred Brand/Non-Preferred Generic (Tier 4)
Specialty/Injectables (Tier 5)
Standard Drugs/30-day supply $0 per prescription
$15 per prescription $40 per prescription2
$100 per prescription2 20% per prescription2
Participating Mail Order Pharmacy
Select Generic/ACA (Tier 1) deductible waived
Preferred Generic (Tier 2) deductible waived
Preferred Brand/Non-Preferred Generic (Tier 3)
Non-Preferred Brand/Non-Preferred Generic (Tier 4)
Specialty/Injectables (Tier 5)
Maintenance Drugs/90-day supply $0 per prescription
$45 per prescription $120 per prescription2
$300 per prescription2
20% per prescription2
1Subject to medical deductible 2Subject to prescription drug deductible
Gross Monthly Cost for Coverage Effective September 1, 2016 - August 31, 2017
Coverage Category Total Cost - Active*
Employee only $472.50
Employee and spouse $1,180.50
Employee and child(ren) $748.50
Employee and family $1,190.50
*District and state fund are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.
15
MEDlink® is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co-payments and coinsurance of your medical plan.
About this Benefit
MEDlink®
DID YOU KNOW?
33%
of total healthcare costs are paid out-of-pocket.
AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 16
MEDlink® Limited Benefit Medical Expense Supplemental Insurance
SUMMARY OF BENEFITS
Base Policy Option 1 Option 2
In-Hospital Benefit - Maximum In-Hospital Benefit $1,500 per confinement $2,500 per confinement
Outpatient Benefit up to $200 per treatment up to $200 per treatment
Physician Outpatient Treatment Benefit $25 per treatment; $125 max per family per Calendar Year
$25 per treatment; $125 max per family per Calendar Year
MEDlink® is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co-payments and coinsurance of your medical plan.
About this Benefit
MEDlink® YOUR
BENEFITS
DID YOU KNOW?
33%
of total healthcare costs are paid
out-of-pocket.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the West Texas EBC
Benefits Website: www.mybenefitshub.com/wtxebc
AMERICAN PUBLIC LIFE THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A
SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES
THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’
COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.
Eligibility This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later.
Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above.
A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.
In-Hospital Benefit Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.
Outpatient Benefits Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.
Physician Outpatient Treatment Benefit Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.
APSB-22330(TX)-0116 MGM/FBS WTXEBC
WTXEBC
Option 1 Total Monthly Premiums by Plan*
Issue Ages 55-59 Issue Ages 60-69
Employee Only $32.00 $49.00
Employee + Spouse $59.00 $88.00
Employee + Child(ren) $47.00 $64.00
Family Coverage
Issue Ages 17-54
$21.50
$39.50
$36.50
$54.50 $74.00 $103.00
Option 2 Total Monthly Premiums by Plan*
Issue Ages 55-59 Issue Ages 60-69
Employee Only $44.50 $68.50
Employee + Spouse $81.50 $122.50
Employee + Child(ren) $62.00 $86.00
Family Coverage
Issue Ages 17-54
$28.00
$51.50
$45.50
$69.00 $99.00 $140.00
17
Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased.
This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.
Exclusions We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered
Dependent spouse: (1) where Your or Your Dependent spouse’s life would be
endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion;
(f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or
unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority;
(h) commission of a felony; (i) participation in a contest of speed in power driven vehicles,
parachuting, or hang gliding; (j) air travel, except:
(1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or
(2) as a passenger for transportation only and not as a pilot or crew member;
(k) intoxication; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.)
(l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed;
(m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while
performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.)
(p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.)
(q) mental illness or functional or organic nervous disorders, regardless of the cause;
(r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (1) resulting from an Accident occurring while the Covered
Person’s coverage is in force and if performed within 12 months of the date of such Accident; or
(2) due to congenital disease or anomaly of a covered newborn child.
(s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborn care;
(t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or
(u) air or ground ambulance.
Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy.
Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage.
We may end the coverage of any Covered Person who submits a fraudulent claim.
We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.
MEDlink® Limited Benefit Medical Expense Supplemental Insurance
This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | WTXEBC
APSB-22330(TX)-0116 MGM/FBS WTXEBC
2305 Lakeland Drive | Flowood, MS 39232
ampublic.com | 800.256.8606
18
MEDlink® Limited Benefit Medical Expense Supplemental Insurance
19
Telehealth provides 24/7/365 access to board-certified doctors via telephone consultations that can diagnose, recommend treatment and prescribe medication. Whether you are at home, traveling or at work, Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.
About this Benefit
Telehealth
DID YOU KNOW?
75%
of all doctor, urgent care, and ER visits could be handled safely and effectively via
telehealth.
MDLIVE YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 20
Telehealth
When should I use MDLIVE? If you’re considering the ER or urgent care for a non-
emergency medical issue
Your primary care physician is not available
At home, traveling, or at work
24/7/365, even holidays!
What can be treated? Allergies
Asthma
Bronchitis
Cold and Flu
Ear Infections
Joint Aches and Pain
Respiratory Infection
Sinus Problems
And More!
Pediatric Care related to: Cold & Flu
Constipation
Ear Infection
Fever
Nausea & Vomiting
Pink Eye
And More!
Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.
Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.
How much does it cost?
$9.00 Voluntary One cost covers entire family with unlimited phone consultations.
Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp
Access to a doctor anywhere: at home, at work, or on the go
Choose doctors from one of the nation's largest telehealth networks
Available 24/7 by video or phone
Private, secure and confidential visits
Connect instantly with MDLIVE Assist
Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113
Call us at (888) 365-1663 or visit us at www.consultmdlive.com
Scan with your smartphone to get the app.
21
Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.
About this Benefit
Dental
Good dental care may improve your overall health.
Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.
DID YOU KNOW?
CIGNA YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 22
Dental PPO - High Option
Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.
Benefits Cigna Dental PPO
In-Network Out-of-Network
Network Total Cigna DPPO
Calendar Year Maximum (Class I, II, III and IX expenses)
Year 1: $1,000 Year 2: $1,250# Year 3 and beyond: $1,500+
Year 1: $1,000 Year 2: $1,250# Year 3 and beyond: $1,500+
Annual Deductible Individual Family
$50 per person $150 per family
$50 per person $150 per family
Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and
Customary Allowances
Plan Pays You Pay Plan Pays You Pay
Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application Sealants Space Maintainers Histopathologic Exams
100% No Charge 100% No Charge
Class II - Basic Restorative Care Fillings Anesthetics Oral Surgery—Simple extractions
80%* 20%* 80%* 20%*
Class III - Major Restorative Care Crowns/Bridges/Dentures Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Oral Surgery—All except simple extractions Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Brush Biopsies Inlays/Onlays Prosthesis Over Implant
50%* 50%* 50%* 50%*
Class IV - Orthodontia Lifetime Maximum
50% $1,000
Dependent children to age 26
50%
50% $1,000
Dependent children to age 26
50%
Class IX - Implants 50%* 50%* 50%* 50%*
Monthly PPO Premiums
Tier Rate
EE Only $31.27
EE + Spouse $59.78
EE + Child(ren) $76.13
Family Coverage $104.73
23
Dental PPO - Low Option
Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.
Benefits Cigna Dental PPO
In-Network Out-of-Network
Network Total Cigna DPPO
Calendar Year Maximum (Class I, II, III and IX expenses)
Year 1: $1,000 Year 2: $1,250# Year 3 and beyond: $1,500+
Year 1: $1,000 Year 2: $1,250# Year 3 and beyond: $1,500+
Annual Deductible Individual Family
$50 per person $150 per family
$50 per person $150 per family
Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and
Customary Allowances
Plan Pays You Pay Plan Pays You Pay
Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application
80% 20% 80% 20%
Class II - Basic Restorative Care Fillings Anesthetics Oral Surgery—Simple extractions
50%* 50%* 50%* 50%*
Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Oral Surgery—All except simple extractions Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant
50%* 50%* 50%* 50%*
Class IV - Orthodontia Lifetime Maximum
50% $1,000
Dependent children to age 26
50%
50% $1,000
Dependent children to age 26
50%
Class IX - Implants 50%* 50%* 50%* 50%*
Monthly PPO Premiums
Tier Rate
EE Only $17.46
EE + Spouse $33.44
EE + Child(ren) $42.43
Family Coverage $58.50
24
Dental PPO - High and Low Options
Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:
100% coverage for certain dental procedures guidance on behavioral issues related to oral health discounts on prescription and non-prescription dental products
For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1 and 2
Procedure Exclusions and Limitations Late Entrants Limit 50% coverage on Class III and IV for 12 months Exams Two per Calendar year Prophylaxis (Cleanings) Two per Calendar year Fluoride 1 per Calendar year for people under 19 Histopathologic Exams Various limits per Calendar year depending on specific test X-Rays (routine) Bitewings: 2 per Calendar year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses
Benefit Exclusions Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat
conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to
a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings,
parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public
program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply
with a “no fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.
In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.
25
Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.
About this Benefit
Vision
75%
DID YOU KNOW?
of U.S. residents between age 25 and 64 require some sort of vision
correction.
SUPERIOR VISION YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 26
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. ₂See your benefits materials for definitions of standard and specialty contact lens fittings. ₃Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4Contact lenses are in lieu of eyeglass lenses and frames benefit.
Vision
Discount Features
Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary. Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) plastic lenses. 5Discounts and maximums may vary by lens type. Please check with your
provider.
Maximum Member Out-of-Pocket
Single Vision Bifocal & Trifocal
Scratch coat $13 $13
Ultraviolet coat $15 $15
Tints, solid or gradients $25 $25
Anti-reflective coat $50 $50
Polycarbonate $40 20% off retail
High index 1.6 $55 20% off retail
Photochromics $80 20% off retail
Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail
Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance.
All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.
Discounts are subject to change without notice.
Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.
Co-Pays
Exam $10
Materials₁ $25
Contact Lens Fitting (standard & specialty)
$0
Services/Frequency
Exam 12 months
Frame 12 months
Contact Lens Fitting 12 months
Lenses 12 months
Contact Lenses 12 months
Benefits In-Network Out-of-Network
Exam (ophthalmologist) Covered in full Up to $42 retail
Exam (optometrist) Covered in full Up to $37 retail
Frames $125 retail allowance Up to $68 retail
Contact Lens Fitting (standard₂) Covered in full Not Covered
Contact Lens Fitting (specialty₂) $50 retail allowance Not Covered
Progressive Lens Upgrade See description3 Up to $61 retail
Contact Lenses4 $120 retail allowance Up to $100 retail
Lenses (standard) per pair
Single Vision Covered in full Up to $32 retail
Bifocal Covered in full Up to $46 retail
Trifocal Covered in full Up to $61 retail
Scratch coat (factory) Covered in full Not Covered
Monthly Premiums
EE Only $8.67
EE + Spouse $17.18
EE + Child(ren) $16.85
EE + Family $25.61
₁ Materials co-pay applies to lenses & frames only, not contact lenses.
27
Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
About this Benefit
Just over 1 in 4 of today's 20 year-olds will become disabled before
they retire.
DID YOU KNOW?
34.6 months is the duration of the
average disability claim.
YOUR BENEFITS PACKAGE Disability
AETNA
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 28
Am I eligible for coverage? You qualify if you are an active full time employee working at least 20 hours a week.
When does coverage become effective? Your Short-Term Disability coverage will begin on 09/01/2015. You must be actively-at-work before your coverage will begin.
Do I have to provide proof of good health (EOI) to enroll? Proof of good health, known as "Evidence of Insurability (EOI)" is not required if you enroll during this benefit election period in the Voluntary Short-Term Disability insurance plan.
How much Voluntary Short-Term Disability can I buy through my employer? A plan that pays a weekly benefit based on a percentage of your Pre-disability Earnings* for a covered disability. You must submit a claim and be approved by Aetna to receive benefits: *Generally, Pre-disability Earnings include your total income before taxes and any deductions for pre-tax contributions. Please consult your Policy Documents available through your employer for additional information, including definition of Pre-disability Earnings.
Are all types of illnesses and injuries covered? Generally, Short-Term Disability (STD) does not replace Workers’ Compensation. STD pays benefits for illnesses or injuries that are unrelated to your occupation or workplace. Normal pregnancy is covered, with any pregnancy-related complications treated same as illness.
When am I considered disabled? You are considered to be totally disabled after a significant mental or physical change resulting from a disease, injury, or a disabling pregnancy-related condition, causes you to be unable to perform the substantial and material acts necessary for your own occupation. Also, as a result, your earnings are 80%, or less, than your pre-disability earnings. If your occupation requires a professional license or certification, you will not be considered disabled solely because you lose your license or certification.
Short Term Disability
Voluntary Short-Term Disability
Employee-paid Plan
Percentage of weekly Income replacement:
60%
Maximum weekly benefit: $500
Benefits begin after a covered: Injury: Illness:
15 days 15 days
Benefits end at recovery or: whichever comes first
11 weeks
29
Short Term Disability
Are there any exclusions that apply to Short-Term Disability? Exclusions You will not receive benefits under certain circumstances. Examples include:
Your disability results from an intentional self-inflicted injury; or you became injured while committing a criminal act or while driving under the influence of alcohol/drugs.
You are not under the regular care of a doctor when requesting disability benefits.
Your disability is covered under a worker’s compensation plan and/or is due to a job-related illness or injury. Pre-existing Conditions Pre-existing Conditions may affect the benefits paid by your Short-Term Disability policy:
A pre-existing condition is an illness, injury or pregnancy-related condition for which you were diagnosed, received medical treatment, or prescribed medications during the 3 month period before your coverage effective date.
No benefit will be paid during the first 12 consecutive months after your coverage effective date for a disability related to a pre-existing condition.
Benefits will be paid for covered disabilities not related to a pre-existing condition. Please refer to your policy documents for a complete list of income sources that will reduce your benefits, as well as a complete list of exclusions and limitations.
Is there anything else I should know about my plan? Recurring Disabilities If you return to work and become disabled again from the same illness or injury, it may be considered the same disability. You will only have to satisfy one elimination period and may be eligible to begin receiving benefits immediately if the disability recurs within 15 consecutive days of your return to work. Partial Disabilities Partial disability benefits allow you to work, earn income and continue receiving benefits so you can receive up to 100% of your income during your disability. You are considered partially disabled if, due to an injury or illness:
You are unable to perform the main duties of your own occupation
And you are earning 80% or less than your Pre-disability Earnings Rehabilitation Our goal is to help you return to gainful employment. Consultants will review each claim to determine if rehabilitation services would be appropriate and effective. We will contact you if we feel you would benefit from these services.
30
Short Term Disability
How do I file a Short-Term Disability? Customer Service Toll-free Number: 888-266-2917 Hours: 8 a.m. to 5 p.m., EST Monday through Friday See your employer for forms and information for filing a claim
How much does Voluntary Short-Term Disability cost? Monthly Rates per $10 of Weekly Benefit: Rates will increase as you move from one age band to another.
Premium Calculation
*Subject to $500.00 maximum weekly benefit.
Age Bands
<20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 75-79 70-74 65-69 60-64 80+
Rate $0.640 $0.640 $0.730 $0.590 $0.470 $0.420 $0.390 $0.470 $0.600 $0.800 $0.800 $0.800 $0.710 $0.800
Calculation:
Step 1: Annual Salary _____________ / 52 = ___________ Weekly Salary
Step 2: Weekly Salary ____________ x ________ % Percentage of Benefit = __________ Weekly Benefit*
Step 3: Weekly Benefit __________ / 10 = ___________ # Units
Step 4: # Units ___________ x ___________ Rate = $ _________ Premium Per Month
Step 5: Monthly Premium ________ x 12 = ________ Annual Premium / ______ # Pay Periods = $ ________ Payroll Deduction
Example: Employee-paid Plan, 40 year old, $35,000 annual salary
Step 1: $35,000 / 52 = $673.08 Weekly Salary
Step 2: $673.08 x .60 = $403.85 Weekly Benefit
Step 3: $403.85 / 10 (Units) = 40.39 Units
Step 4: 40.39 x 0.42 (Rate) = $16.96 Premium Per Month
31
Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.
About this Benefit
Cancer
Breast Cancer is the most commonly diagnosed cancer in women.
DID YOU KNOW?
If caught early, prostate cancer is one of the most treatable malignancies.
LOYAL AMERICAN YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 32
Cancer
ADDITIONAL BENEFIT AMOUNTS PLAN A
Maximum PLAN B
Maximum PLAN C
Maximum ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).
B.Additional Benefit We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate.
$50 Per Calendar
Year
$100 Per Calendar
Year
$50 Per Calendar
Year
$100 Per Calendar
Year
$50 Per Calendar
Year
$100 Per Calendar
Year
FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule. If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.
$3,000 Once per Lifetime $4,500
Once per Lifetime
$5,000 Once per Lifetime $7,500
Once per Lifetime
$6,000 Once per Lifetime $9,000
Once per Lifetime
ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045) We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.
$7,500 Per Calendar
Year
$10,000 Per Calendar
Year
$20,000 Per Calendar
Year
SURGICAL BENEFIT RIDER (form LG-6048) Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.
$3,000
Procedure Maximum
$3,000
Procedure Maximum
$6,000
Procedure Maximum
Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.
$750 Procedure Maximum
$750 Procedure Maximum
$1,500 Procedure Maximum
Breast Reconstruction With transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.
Skin Cancer Surgery Expense We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.
$2,700
Procedure Maximum
Per Procedure
$2,700
Procedure Maximum
Per Procedure
$5,400
Procedure Maximum
Per Procedure
DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.
Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.
Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.
$100 Per Day
$200 Per Day
$200/ $400
Per Day
$200 Per Day
$400 Per Day
$400/ $800
Per Day
$200 Per Day
$400 Per Day
$400/ $800
Per Day 33
Cancer
Additional Benefits Amounts SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider.
Covers These 38 Specified Diseases
Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever
Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia
Botulism Meningitis Tay-Sachs Disease
Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus
Budd-Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis
Cystic Fibrosis Myasthenia Gravis Tuberculosis
Diptheria Neimann-Pick Disease Tularemia
Encephalitis Osteomyelitis Typhoid Fever
Epilepsy Poliomyelitis Undulant Fever
Hansen’s Disease Q Fever West Nile Virus
Histoplasmosis Rabies Whipple’s Disease
Legionnaire’s Disease Reye’s Syndrome Whooping Cough
Lyme Disease Rheumatic Fever
Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more. *SPECIFIED DISEASE BENEFIT RIDER IS NOT INCLUDED IN PLAN A
Monthly Rates
Employee
Single Parent
Employee and
Spouse
Family
Base Plan A $19.74 $24.12 $33.18 $33.18
Base Plan B $25.14 $30.32 $41.85 $41.85
Base Plan C $35.89 $42.65 $59.40 $59.40
34
Cancer
OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM
HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047) Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.
$500
Per Day
Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.
$1,000 Per Day
Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.
$250
Per Day
Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner. THIS IS A LIMITED RIDER.
Monthly Rates
Employee
Single Parent
Employee and
Spouse
Family
Base Plan A with ICU $22.06 $27.31 $37.58 $37.58
Base Plan B with ICU $27.46 $33.52 $46.25 $46.25
Base Plan C with ICU $38.21 $45.84 $63.80 $63.80
35
Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.
About this Benefit
Accident
of disabling injuries suffered by American workers are not work related.
DID YOU KNOW?
36% of American workers report they always or usually live paycheck to paycheck.
2/3
AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 36
Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious,injury. Accident coverage is low cost protectionavailable to you and your family without evidence of insurability.
About this Benefit
AccidentYOUR
BENEFITS
A-3 Supplemental Limited Benefit Accident Expense Insurance
THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A
SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES
THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’
COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Summary of Benefits*
Benefit Description Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units
Accidental Death - per unit $5,000 $10,000 $15,000 $20,000
Medical Expense Accidental Injury Benefit - per unit
actual charges up to $500
actual charges up to $1,000
actual charges up to $1,500
actual charges up to $2,000
Daily Hospital Confinement Benefit $75 per day $150 per day $225 per day $300 per day
Air and Ground Ambulance Benefit actual charges up to $1,250
actual charges up to $2,500
actual charges up to $3,750
actual charges up to $5,000
Accidental Dismemberment BenefitSingle finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs
$500 $500
$2,500 $5,000
$1,000 $1,000 $5,000
$10,000
$1,500 $1,500 $7,500
$15,000
$2,000 $2,000
$10,000 $20,000
Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes
$2,500 $5,000
$5,000 $10,000
$7,500 $15,000
$10,000 $20,000
Benefit Rider
Hospital Admission Benefit $100 upon admission
$100 upon admission
$100 upon admission
$100 upon admission
Accident Only—Intensive Care Benefit $150 per day $150 per day $150 per day $150 per day
Individual Individual & Spouse
1 Parent Family
2 Parent Family
Level 1 - 1 Unit $11.70 $20.70 $22.70 $31.70
Level 2 - 2 Units $18.00 $31.10 $36.40 $49.50
Level 3 - 3 Units $22.40 $40.20 $46.70 $64.50
Level 4 - 4 Units $25.40 $46.20 $53.50 $74.30
*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary
dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.
of disabling injuries
suffered by American
workers are not work
related.
DID YOU KNOW?
36% of American workers
report they always or
usually live paycheck
to paycheck.
2/3
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
West Texas Employee Benefit Cooperative Benefits Website: www.mybenefitshub.com/wtxebc
AMERICAN PUBLIC LIFE
APSB-22329(TX)-MGM/FBS WTXEBC
WTXEBC
37
A-3 Supplemental Limited Benefit Accident Expense Insurance A-3 Supplemental Limited Benefit Accident Expense Insurance
Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | West Texas EBC
Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.
Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.
A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.
Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.
Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.
Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.
Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.
Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.
Hospital Admission Benefit The maximum benefit is 4 units.
Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:
(1) sickness, illness or bodily infirmity;(2) suicide, attempted suicide or intentional self-inflicted
Injury, whether sane or insane;(3) dental care or treatment unless due to accidental
Injury to natural teeth;(4) war or any act of war (whether declared or
undeclared) or participating in a riot or felony;(5) alcoholism or drug addiction;(6) travel or flight in or descent from any aircraft or
device which can fly above the earth’s surface in anycapacity other than as a fare paying passenger on aregularly scheduled airline;
(7) Injury originating prior to the effective date of thePolicy;
(8) Injury occurring while intoxicated (Intoxication meansthat which is determined and defined by the laws andjurisdiction of the geographical area in which the lossor cause of loss is incurred.);
(9) Voluntary inhalation of gas or fumes or taking ofpoison or asphyxiation;
(10) Voluntary ingestion or injection of any drug, narcoticor sedative, unless administered on the advice andtaken in such doses as prescribed by a Physician;
(11) Injury sustained or sickness which first manifestsitself while on full-time duty in the armed forces;(Upon notice, We will refund the proportion ofunearned premium while in such forces.)
(12) Injury incurred while engaging in an illegal occupation;(13) Injury incurred while attempting to commit a felony or
an assault;(14) Injury to a covered person while practicing for or being
a part of organized or competitive rodeo, sky diving,hang gliding, parachuting or scuba diving;
(15) driving in any race or speed test or while testing anautomobile or any vehicle on any racetrack orspeedway;
(16) hernia, carpal tunnel syndrome or any complicationtherefrom;
If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.
Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correctpremium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.
APSB-22329(TX)-MGM/FBS WTXEBC APSB-22329(TX)-MGM/FBS West Texas EBC
2305 Lakeland Drive | Flowood, MS 39232
ampublic.com | 800.256.8606
38
A-3 Supplemental Limited Benefit Accident Expense Insurance A-3 Supplemental Limited Benefit Accident Expense Insurance
Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | WTXEBC
Limitations and Exclusions EligibilityThis policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.
Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accidentsustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.
A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest orconvalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.
Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.
Air and Ground Ambulance BenefitEmergency transportation must occur within 21 calendar days of the accident causing such Injury.
Daily Hospital Confinement BenefitThe maximum benefit period for this benefit is 30 days per covered accident.
Accidental DeathAccidental Death must result within 90 days of the covered accident causing the injury.
Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.
Hospital Admission Benefit The maximum benefit is 4 units.
Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:
(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted
Injury, whether sane or insane; (3) dental care or treatment unless due to accidental
Injury to natural teeth;(4) war or any act of war (whether declared or
undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction;(6) travel or flight in or descent from any aircraft or
device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline;
(7) Injury originating prior to the effective date of the Policy;
(8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.);
(9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation;
(10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician;
(11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.)
(12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or
an assault; (14) Injury to a covered person while practicing for or being
a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;
(15) driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway;
(16) hernia, carpal tunnel syndrome or any complication therefrom;
If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.
Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.
APSB-22329(TX)-MGM/FBS West Texas EBC APSB-22329(TX)-MGM/FBS WTXEBC
2305 Lakeland Drive | Flowood, MS 39232
ampublic.com | 800.256.8606
39
Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.
About this Benefit
Critical Illness
Is the aggregate cost of a hospital stay for a heart
attack.
DID YOU KNOW?
$16,500
UNUM YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 40
Critical Illness
Without Cancer Monthly Rates per $1,000
Issue Age Non-Tobacco Tobacco
Under 25 $0.29 $0.29
25-29 $0.30 $0.30
30-34 $0.44 $0.44
35-39 $0.60 $0.60
40-44 $0.89 $0.89
45-49 $1.17 $1.17
50-54 $1.53 $1.53
55-59 $1.98 $1.98
60-64* $2.54 $2.54
65-69 $2.91 $2.91
70+ $5.44 $5.44
Wellness Benefit - Additional Monthly Cost per $50
Employee and Children $1.60
Spouse $1.60
How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $10,000 to $30,000 - and you can use the money any way you see fit.
Covered Conditions Heart attack
Major organ failure
Occupational HIV
Benign brain tumor
Blindness
End-stage renal (kidney) failure
Coronary artery bypass surgery; pays 25% of lump sum benefit
Covered Conditions With Time Limitations Stroke—Evidence of persistent neurological deficits
confirmed by a neurologist at least 30 days after the event
Coma—Coma resulting from severe traumatic brain injury lasting for a period of 14 or more consecutive days
Permanent paralysis—Complete and permanent loss of the use of two or more limbs for continuous 90 days as a result of a covered accident
Available Family Coverage
Reduction of Benefits The benefit amount for the employee and spouse reduces by 50% on the first policy anniversary date after the insured
individual’s 70th birthday. Premiums will not be reduced. For coverage purchased after age 70, benefit amounts will not be reduced.
Benefit Overview
Critical illness insurance is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit if an insured is diagnosed with a covered critical illness. The Critical Illness benefit is based on the amount of coverage in effect on the date of diagnosis of a critical illness or the date treatment is received according to the terms and provisions of the policy. Coverage Amounts Employee - $10,000 to $30,000 in increments of $5,000 Spouse - $5,000 to $15,000 in increments of $5,000 Child - 25% of Employee Coverage Amount Guarantee Issue Employee - $30,000 Spouse - $15,000 Pre-Existing Condition 12/12 exclusion Portability Included Wellness Benefit $50 per insured per calendar year Recurrence Benefit Included - 25% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke. Premium Paid by the Employee Rate Information Wellness benefit premium is in addition to the base premium. Who can have it? Benefit
Employees who are actively at work
$10,000 to $30,000 in $5,000
increments
Dependent children
newborn until their 26th
birthday, regardless of
marital or student status
All eligible children are
automatically covered
at 25% of the employee
benefit amount (no
additional cost)
Eligible children are covered
for the same conditions as
employee and the following
specific childhood conditions:
cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome and spina bifida.
Diagnosis must occur after the child’s coverage effective date.
Spouse ages 17 through
64 with purchase of
employee coverage
From $5,000 to $15,000 in $5,000 increments
41
Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.
About this Benefit
Life and AD&D
cause of accidental deaths in the US, followed by poisoning, falls,
drowning, and choking.
DID YOU KNOW?
#1
Motor vehicle crashes are the
UNUM YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 42
Life and AD&D
Basic Group Term Life and AD&D Amounts vary by district from $10,000 to $50,000. Refer to www.wtxebc.com for a list of school districts.
Voluntary Group Term Life All full time active employees of participating independent school districts working at least 20 hours per week may elect voluntary life coverage for themselves and their eligible dependents. The amount of life insurance coverage for a dependent will not be more than 100% of the employee life amount. The employee must be covered in order to insure the dependents for life. Employees and/or spouses who do not enroll during their initial eligibility period must prove Evidence of Insurability for full amount applied for. Guarantee Issue and Benefit Maximum: Employee: $200,000 Guaranteed Issue, Overall maximum 7x annual earnings up to $500,000 Spouse: $50,000 Guaranteed Issue, Overall maximum up to $500,000 not to exceed 100% of employee amount Child: Option 1: $5,000 and Option 2: $10,000, Guaranteed Issue Child age is 6 months to 26 years, Birth to 14 days $1,000 benefit, 14 days to 6 month $2,000 benefit. Coverage for employee and spouse reduces 65% at age 65 and 50% at age 70. If your eligible dependent is totally disabled, your dependent's coverage will begin on the first of the month coincident with or next following the date your eligible dependent no longer is totally disabled. This provision does not apply to a newborn child while dependent insurance is in effect.
Your Basic and Voluntary Life Insurance automatically includes: Wavier of Premium: Life insurance premiums will be
waived for insured employees who become disabled prior to a specified age, and who remain disabled during an elimination period.
Accelerated Death Benefit: Pays a portion of the insured employee’s or dependent’s Life benefit in the event the insured employee or dependent becomes terminally ill and the employee’s or dependent’s life expectancy has been reduced to less than 12 months. The employee’s or dependent’s death benefit will be reduced by the Accelerated Life Benefit paid.
Portability Privilege: Allows an insured employee and their dependents to elect portable coverage at group rates, if the employee terminates employment, reduces hours or retires from the employer. Employees and their
dependents are not eligible for portable coverage if they have an injury or sickness, under the terms of this plan, that has a material effect on life expectancy.
Conversion Privilege: When an insured employee’s group coverage ends, employees and their dependents may convert their coverage to individual life policies without providing evidence of insurability.
DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.
43
Life and AD&D
Coverage <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+
$10,000 $0.54 $0.72 $0.81 $0.99 $1.53 $2.88 $4.95 $7.92 $11.04 $18.54
$20,000 $1.08 $1.44 $1.62 $1.98 $3.06 $5.76 $9.90 $15.84 $22.08 $37.08
$30,000 $1.62 $2.16 $2.43 $2.97 $4.59 $8.64 $14.85 $23.76 $33.12 $55.62
$40,000 $2.16 $2.88 $3.24 $3.96 $6.12 $11.52 $19.80 $31.68 $44.16 $74.16
$50,000 $2.70 $3.60 $4.05 $4.95 $7.65 $14.40 $24.75 $39.60 $55.20 $92.70
$60,000 $3.24 $4.32 $4.85 $5.94 $9.18 $17.28 $29.70 $47.52 $66.24 $111.24
$70,000 $3.78 $5.04 $5.67 $6.93 $10.71 $20.16 $34.65 $55.44 $77.28 $129.78
$80,000 $4.32 $5.76 $6.48 $7.92 $12.24 $23.04 $39.60 $63.36 $88.32 $148.32
$90,000 $4.86 $6.48 $7.29 $8.91 $13.77 $25.92 $44.55 $71.28 $99.36 $166.86
$100,000 $5.40 $7.20 $8.10 $9.90 $15.30 $28.80 $49.50 $79.20 $110.40 $185.40
$110,000 $5.94 $7.92 $8.91 $10.89 $16.83 $31.68 $54.45 $87.12 $121.44 $203.94
$120,000 $6.48 $8.64 $9.72 $11.88 $18.36 $34.56 $59.40 $94.04 $132.48 $222.48
$130,000 $7.02 $9.36 $10.53 $12.87 $19.89 $37.44 $64.35 $102.96 $143.52 $241.02
$140,000 $7.56 $10.08 $11.34 $13.86 $21.42 $40.32 $69.30 $110.88 $154.56 $259.56
$150,000 $8.10 $10.80 $12.15 $14.85 $22.95 $43.20 $74.25 $118.80 $165.60 $278.10
$160,000 $8.64 $11.52 $12.96 $15.84 $24.48 $46.08 $79.20 $126.72 $176.64 $296.64
$170,000 $9.18 $12.24 $13.77 $16.83 $26.01 $48.96 $84.15 $134.64 $187.68 $315.18
$180,000 $9.72 $12.96 $14.58 $17.82 $27.54 $51.84 $89.10 $142.56 $198.72 $333.72
$190,000 $10.26 $13.68 $15.39 $18.81 $29.07 $54.72 $94.05 $150.48 $209.76 $352.26
$200,000 $10.80 $14.40 $16.20 $19.80 $30.60 $57.60 $99.00 $158.40 $220.80 $370.80
Monthly Cost for Voluntary Term Life Insurance: Coverage amounts and rates for employee and spouse are shown below in increments of $10,000, by age bands. Child Life Monthly Rates are $1.00 for $5,000 and $2.00 for $10,000 of coverage.
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Life and AD&D
Voluntary Group Accidental Death All full time active employees of participating independent school districts working at least 20 hours per week may elect voluntary AD&D coverage for themselves and their eligible dependents. Employees are not required to purchase life insurance in order to purchase individual or family AD&D coverage. The Individual Plan covers you in the event of accidental death or dismemberment. Benefits are available in $10,000 increments to a maximum of $500,000. The cost of this coverage is $0.04 per $1,000. The Family Plan covers you and your eligible dependents in the event of accidental death or dismemberment. Benefits are available in $10,000 increments to a maximum of $500,000 for employee and 50% of employee amount for spouse with a maximum of $250,000 and 10% of the employee amount for the dependent child with a maximum amount of $50,000. The cost of this coverage is $0.07 per $1,000.
45
5STAR
Individual Life YOUR BENEFITS PACKAGE
Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.
About this Benefit
x 10
Experts recommend at least
your gross annual income in coverage when purchasing life insurance.
DID YOU KNOW?
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 46
Term Life with Terminal Illness and Quality of Life Rider
The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected. If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis—4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance. Benefits are paid for the following:
Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or
A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision.
For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary. * Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.
Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.
Example Weekly
Premium Death
Benefit Accelerated
Benefit
Your age at issue: 35
$10.00 $89,655 4%
$3,586.20 a month
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Term Life with Terminal Illness and Quality of Life Rider
MONTHLY RATES WITH QUALITY OF LIFE RIDER
DEFINED BENEFIT
Age on App. Date
Employee Coverage Amounts Spouse Coverage Amounts
$10,000 $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000
18-25 $7.56 $12.40 $20.46 $28.52 $36.58 $7.56 $10.78 $14.01
26 $7.58 $12.46 $20.58 $28.71 $36.83 $7.58 $10.83 $14.08
27 $7.65 $12.63 $20.92 $29.21 $37.50 $7.65 $10.97 $14.28
28 $7.74 $12.85 $21.38 $29.90 $38.42 $7.74 $11.15 $14.56
29 $7.88 $13.21 $22.08 $30.96 $39.83 $7.88 $11.43 $14.98
30 $8.07 $13.67 $23.00 $32.33 $41.67 $8.07 $11.80 $15.53
31 $8.27 $14.17 $24.00 $33.83 $43.67 $8.27 $12.20 $16.13
32 $8.49 $14.73 $25.13 $35.52 $45.92 $8.49 $12.65 $16.81
33 $8.73 $15.31 $26.29 $37.27 $48.25 $8.73 $13.12 $17.51
34 $9.00 $16.00 $27.67 $39.33 $51.00 $9.00 $13.67 $18.33
35 $9.30 $16.75 $29.17 $41.58 $54.00 $9.30 $14.27 $19.23
36 $9.64 $17.60 $30.88 $44.15 $57.42 $9.64 $14.95 $20.26
37 $10.02 $18.54 $32.75 $46.96 $61.17 $10.02 $15.70 $21.38
38 $10.41 $19.52 $34.71 $49.90 $65.08 $10.41 $16.48 $22.56
39 $10.84 $20.60 $36.88 $53.15 $69.42 $10.84 $17.35 $23.86
40 $11.31 $21.77 $39.21 $56.65 $74.08 $11.31 $18.28 $25.26
41 $11.83 $23.08 $41.83 $60.58 $79.33 $11.83 $19.33 $26.83
42 $12.41 $24.52 $44.71 $64.90 $85.08 $12.41 $20.48 $28.56
43 $13.00 $26.00 $47.67 $69.33 $91.00 $13.00 $21.67 $30.33
44 $13.63 $27.56 $50.79 $74.02 $97.25 $13.63 $22.92 $32.21
45 $14.28 $29.19 $54.04 $78.90 $103.75 $14.28 $24.22 $34.16
46 $14.97 $30.92 $57.50 $84.08 $110.67 $14.97 $25.60 $36.23
47 $15.69 $32.73 $61.13 $89.52 $117.92 $15.69 $27.05 $38.41
48 $16.43 $34.56 $64.79 $95.02 $125.25 $16.43 $28.52 $40.61
49 $17.22 $36.54 $68.75 $100.96 $133.17 $17.22 $30.10 $42.98
50 $18.08 $38.69 $73.04 $107.40 $141.75 $18.08 $31.82 $45.56
51 $19.04 $41.10 $77.88 $114.65 $151.42 $19.04 $33.75 $48.46
52 $20.16 $43.90 $83.46 $123.02 $162.58 $20.16 $35.98 $51.81
53 $21.40 $47.00 $89.67 $132.33 $175.00 $21.40 $38.47 $55.53
54 $22.79 $50.48 $96.63 $142.77 $188.92 $22.79 $41.25 $59.71
55 $24.27 $54.17 $104.00 $153.83 $203.67 $24.27 $44.20 $64.13
56 $25.93 $58.33 $112.33 $166.33 $220.33 $25.93 $47.53 $69.13
57 $27.66 $62.65 $120.96 $179.27 $237.58 $27.66 $50.98 $74.31
58 $29.42 $67.04 $129.75 $192.46 $255.17 $29.42 $54.50 $79.58
59 $31.23 $71.56 $138.79 $206.02 $273.25 $31.23 $58.12 $85.01
60 $33.12 $76.29 $148.25 $220.21 $292.17 $33.12 $61.90 $90.68
61 $35.08 $81.19 $158.04 $234.90 $311.75 $35.08 $65.82 $96.56
62 $37.13 $86.31 $168.29 $250.27 $332.25 $37.13 $69.92 $102.71
63 $39.31 $91.77 $179.21 $266.65 $354.08 $39.31 $74.28 $109.26
64 $41.68 $97.71 $191.08 $284.46 $377.83 $41.68 $79.03 $116.38
65 $44.33 $104.33 $204.33 $304.33 $404.33 $44.33 $84.33 $124.33
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Term Life with Terminal Illness and Quality of Life Rider
MONTHLY RATES WITH QUALITY OF LIFE RIDER
DEFINED BENEFIT
Age on App. Date
Employee Coverage Amounts Spouse Coverage Amounts
$10,000 $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000
66* $44.93 $105.81 $207.29 $308.77 $410.25 $44.93 $85.52 $126.11
67* $48.25 $114.13 $223.92 $333.71 $443.50 $48.25 $92.17 $136.08
68* $52.03 $123.58 $242.83 $362.08 $481.33 $52.03 $99.73 $147.43
69* $56.33 $134.31 $264.29 $394.27 $524.25 $56.33 $108.32 $160.31
70* $61.17 $146.42 $288.50 $430.58 $572.67 $61.17 $118.00 $174.83
*Qualify of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: full term new born to 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.
49
Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.
About this Benefit
Identity Theft ID WATCHDOG
An identity is stolen every
2 seconds, and takes over
300 hours to resolve, causing an
average loss of $9,650.
DID YOU KNOW?
YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 50
Identity Theft
Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.
Identity theft devastates its victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.
Repairing the damage caused by identity theft is frustrating and time consuming. The average victim spends 330 hours repairing the damage from identity theft—the equivalent of working a full-time job for more than 2 months.
The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.
Who’s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies
ID Watchdog Monthly Rates
Individual Plan $7.95
Family Plan $14.95
Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee
ID Watchdog Services
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Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter.
About this Benefit
Medical Transport MASA
A ground ambulance can cost up to
$2,400 and a helicopter
transportation fee can cost
over $30,000
DID YOU KNOW?
YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com 52
Medical Transport
MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network, which means you are covered anywhere.
THE TRUTH... Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or critical care transport. The reality is that a majority of Americans are only partially covered for these high costs. Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill. You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill. We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short. “All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015
MASA MTS for Employees Ensures... NO health questions
NO age limits
NO claim forms
NO deductibles
NO provider network limitations
NO dollar limits on emergency transport costs
What is Covered? Emergency Helicopter Transport
Emergency Ground Ambulance Transport
How Much Does It Cost?
MASA Emergent rates are $9 a month, per employee only/family coverage.
Emergent Card Example:
53
A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.
Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.
About this Benefit
FSA (Flexible Spending Account)
NBS YOUR BENEFITS PACKAGE
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the
WTXEBC Benefits Website: www.wtxebc.com
FOR HSA VS. FSA COMPARISON
FLIP TO… PG. 11
54
NBS Flexcard You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.
Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you throw away your cards, there is a $5.00 fee to replace them.
New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.
FSA Annual Contribution Max: $2,550
Dependent Care Annual Max: $5,000
Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com
Detailed claim history and processing status
Health Care and Dependent Care account balances
Claim forms, Direct Deposit form, worksheets, etc.
Online claims
FAQs
For a list of sample expenses, please refer to the WTXEBC benefit website: www.wtxebc.com
NBS Contact Information:
8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: [email protected]
When Will I Receive My Flex Card? Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!
FSA (Flexible Spending Account)
DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses.
NBS Prepaid MasterCard® Debit Card
55
What is a Flexible Spending Account? A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.
How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.
Health Care Expense Account Example Expenses:
Dependent Care Expense Account Example Expenses: Before and After School and/or Extended Day Programs
The actual care of the dependent in your home.
Preschool tuition.
The base costs for day camps or similar programs used as care for a qualifying individual.
What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.wtxebc.com
What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).
How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.wtxebc.com and complete the “Claim Form” to send to NBS or use the web or phone app to file online.
Hearing aids & batteries
Lab fees
Laser Surgery
Orthodontia Expenses
Physical exams
Pregnancy tests
Prescription drugs
Vaccinations
Vaporizers or humidifiers
Acupuncture
Body scans
Breast pumps
Chiropractor
Co-payments
Deductible
Diabetes Maintenance
Eye Exam & Glasses
Fertility treatment
First aid
FSA Frequently Asked Questions
How To Receive Your Dependent Care Reimbursement Faster.
A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!
56
How the FSA Plan Works
You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.
Get Your Money 1. Complete and sign a claim form (available on our website) or an online claim. 2. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. 3. Fax or mail signed form and documentation to NBS. 4. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.
NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.
Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes:
Detailed claim history and processing status
Health Care and Dependent Care account balances
Claim forms, worksheets, etc.
Online Claim Submission
Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds.
57
NOTES
58
NOTES
59
www.wtxebc.com
60