ALAMO HEIGHTS ISD
BENEFIT GUIDE EFFECTIVE: 09/01/2018 - 8/31/2019 WWW.MYBENEFITSHUB.COM/ ALAMOHEIGHTSISD
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Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA)
3 4-5 6-11 6 7 8 9 10
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TRS ActiveCare
12-13
MDLIVE Telehealth Avesis Medical Gap Plan
14-15
Cigna Dental and Humana DHMO
18-25
Superior Vision
26-27
The Hartford Disability
28-33
Humana Cancer
34-35
Humana Accident
38-41
Aflac Critical Illness
42-45
NBS Flexible Spending Account (FSA)
46-49
HSA Bank Health Spending Account (HSA)
50-53
AUL a OneAmerica Company Life and AD&D
54-57
MASA Medical Transport
58-59
The Hartford Hospital Indemnity
60-61
Texas Life Individual Life
62-63
Deer Oaks Employee Assistance Program (EAP)
64-65
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FLIP TO... PG. 4 HOW TO HOW TO ENROLL ENROLL
16-17
PG. 6 SUMMARY PAGES
PG. 12 YOUR BENEFITS
Benefit Contact Information ALAMO HEIGHTS BENEFITS
VISION
MEDICAL GAP PLAN
Financial Benefit Services Superior Vision (800) 583-6908 (800) 507-3800 www.mybenefitshub.com/alamoheightsisd www.superiorvision.com
Avesis 855) 214-6777 www.avesis.com
TELEHEALTH
DISABILITY
CRITICAL ILLNESS
MDLIVE (888) 365-1663 www.consultmdlive.com
The Hartford (800) 303-9744 File a claim: (866) 278-2655 www.thehartford.com
Aflac (800) 992-3522 www.aflac.com
MEDICAL GAP PLAN
CANCER
VOLUNTARY GROUP LIFE
Avesis (855) 214-6777 www.avesis.com
Humana (800) 448-6262 www.humana.com
AUL a OneAmerica Company (800) 553-5318 www.oneamerica.com
DENTAL PPO
ACCIDENT
FLEXIBLE SPENDING ACCOUNT
Cigna (800) 244-6224 www.cigna.com
Humana (800) 448-6262 www.humana.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
DENTAL DHMO
HOSPITAL INDEMNITY
HEALTH SAVINGS ACCOUNT
Humana (800) 233-4013 www.humana.com
The Hartford (800) 303-9744 www.thehartford.com
HSA Bank (800) 357-6246 www.hsabank.com
MEDICAL TRANSPORT
TRS ACTIVECARE MEDICAL
INDIVIDUAL LIFE
MASA (800) 423-3226 www.masamts.com
Aetna (800) 222-9205 www.trsactivecareaetna.com
Texas Life (800) 283-9233 www.texaslife.com
EMPLOYEE ASSISTANT PROGRAM Deer Oaks (866) 327-2400
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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS AHISD to 313131 and get access to everything you need to complete your benefits enrollment:
Benefit Information
Online Support
Interactive Tools
And more. PLAY VIDEO
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Text “FBS AHISD” to 313131 OR SCAN
How to Log In
1 BENEFIT INFO
INTERACTIVE TOOLS
2 3
www.mybenefitshub.com/ alamoheightsisd
CLICK LOGIN
ENTER USERNAME & PASSWORD 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.
ONLINE SUPPORT
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.
Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.
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Annual Benefit Enrollment
SUMMARY PAGES
Benefit Updates - What’s New: TRS MEDICAL—All of the TRS medical plans will
FLEXIBLE SPENDING ACCOUNT—NEW! Annual maximum experience a rate increase effective 09/01/2018. contribution limit increased to $2,650 for 2018. ActiveCare 2 will no longer be available for new REMINDER! If you currently participate in a Healthcare or enrollees, however, current participants may elect to Dependent Care FSA, you MUST reelect a new remain on the plan. The deductibles for ActiveCare 1 HD contribution amount every year to continue to have increased as well as the out of pocket maximum. participate. You can view your account balance using the The deductibles for ActiveCare Select will remain the CHECK FSA link on the Benefits website or use the NBS same for the upcoming plan year. As a reminder, smart phone app. It’s important to save your medical ActiveCare 1 HD & ActiveCare 2 have In Network and Out receipts! The IRS requires the Flex Card only be used for of Network Deductibles. Copays for ActiveCare Select eligible expenses. NBS will send you a letter if they need and ActiveCare 2 have increased. For more info on plan receipts to verify an expense. design changes for all TRS ActiveCare plans, please visit www.trsactivecareaetna.com. All ActiveCare enrollees should receive a new medical ID card this year.
DENTAL RATE INCREASE—There is a slight increase in
Dental rates effec ve 09/01/2018, no changes to the plan. HEALTH SAVINGS ACCOUNT (HSA) - NEW! Annual
maximum contribu on limit increased to $3,450 Individual and $6,900 Family for the 2018-2019 Plan Year.
Don’t Forget!
Login and complete your benefit enrollment from 8/1/2018—8/24/2018. Enrollment assistance is available by calling Financial Benefit Services at (800) 583-6908 to speak to a representative. Update your profile information: home address, phone numbers, email. Update dependent social security numbers and student status for college aged children.
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SUMMARY PAGES
Section 125 Cafeteria Plan Guidelines 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.
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.
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. 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 Judgment/Decree/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.
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SUMMARY PAGES
Annual Enrollment During your annual enrollment period, you have the opportunity
Where can I find forms?
to review, change or continue benefit elections each year.
For benefit summaries and claim forms, go to your school
Changes are not permitted during the plan year (outside of
district’s benefit website: www.mybenefitshub.com/
annual enrollment) unless a Section 125 qualifying event occurs.
alamoheightsisd. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you
Changes, additions or drops may be made only during the
need under the Benefits and Forms section.
annual enrollment period without a qualifying event. How can I find a Network Provider?
Employees must review their personal information and verify that dependents they wish to provide coverage for are
district’s website: www.mybenefitshub.com/alamoheightsisd.
included in the dependent profile. Additionally, you must
Click on the benefit plan you need information on (i.e.,
notify your employer of any discrepancy in personal and/or benefit information.
For benefit summaries and claim forms, go to your school
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.
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
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.
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.
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.
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SUMMARY PAGES
Employee Eligibility Requirements
Dependent Eligibility Requirements
Supplemental Benefits: Eligible employees must work 20 or more
Dependent Eligibility: You can cover eligible dependent
regularly scheduled hours each work week.
children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the
Eligible employees must be actively at work on the plan effective
maximum age listed below. Dependents cannot be double
date for new benefits to be effective, meaning you are physically
covered by married spouses within Alamo Heights ISD or as
capable of performing the functions of your job on the first day of
both employees and dependents.
work concurrent with the plan effective date. For example, if your 2018 benefits become effective on September 1, 2018, you must be actively-at-work on September 1, 2018 to be eligible for your new benefits. PLAN
CARRIER
MAXIMUM AGE
Dental (PPO/MAC)
Cigna
To age 26
Dental (DHMO)
Humana
To age 26
Telehealth
MDLIVE
To age 26
Vision
Superior Vision
To age 26
Cancer
Humana
To age 26 if student in accredited school
Accident
Humana
To age 26
Voluntary Life and AD&D
AUL a OneAmerica Company
To age 26
Critical Illness
Aflac
To age 26
Individual Life
Texas Life
To age 26
Emergency Medical Transport
MASA
To age 26
Hospital Indemnity
The Hartford
To age 26
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. 9
SUMMARY PAGES
Helpful Definitions Actively at Work
In-Network
You are performing your regular occupation for the employer
Doctors, hospitals, optometrists, dentists and other providers
on a full-time basis, either at one of the employer’s usual
who have contracted with the plan as a network provider.
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 9/1/2018 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.
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
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.
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(including diagnostic and/or consultation services).
SUMMARY PAGES
HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
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 Account Owner Underlying Insurance Requirement
Employee and/or employer Individual
Employee and/or employer Employer
High deductible health plan
None
Description
Minimum Deductible Maximum Contribution
$1,300 single (2018) $2,600 family (2018) $3,450 single (2018) $6,900 family (2018)
N/A $2,650
Permissible Use Of Funds
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
FLIP TO FOR HSA INFORMATION
PG. 50
FLIP TO FOR FSA INFORMATION
PG. 48
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2018 – 2019 TRS-ActiveCare Plan Highlights Effective September 1, 2018 through August 31, 2019 | In-Network Level of Benefits1
Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays Preventive Care See below for examples Teladoc® Physician Services
High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Participant pays Freestanding Emergency Room Participant pays
$500 copay per visit plus 20% after deductible
$500 copay per visit plus 20% after deductible
$500 copay per visit plus 20% after deductible
Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Participant pays Annual Hearing Examination Participant pays Preventive Care Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smoking cessation counseling– 8 visits per 12 months
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• Well-child care – unlimited up to age 12 • Colonoscopy – 1 every 10 years age 50 and over •Healthydiet/obesity counseling– unlimited to
• Well woman exam & pap smear – annually age 18 and over • Prostatecancerscreening–1 per year age 50 and over • Breastfeeding support – 6 lactation counseling visits
Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after deductible, except for certain generic preventive drugs that are covered at 100%.2 20% coinsurance after deductible 50% coinsurance after deductible Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)5 20% coinsurance after deductible
$20 for a 1- to 31-day supply $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply3 $40 for a 1- to 31-day supply3 50% coinsurance for a 1- to 31-day supply3 50% coinsurance for a 1- to 31-day supply (Min. $654; Max. $130)3
$45 for a 60- to 90-day supply
$45 for a 60- to 90-day supply
$105 for a 60- to 90-day supply3 $105 for a 60- to 90-day supply3 3 50% coinsurance for a 60- to 90-day supply 50% coinsurance for a 60- to 90-day supply3 (min. $1804 , max $360)3 Specialty Medications 20% coinsurance after deductible 20% coinsurance 20% coinsurance (up to a 31-day supply) (min. $2004 , max $900) Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) 20% coinsurance after deductible 50% coinsurance after deductible
Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand
20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible
$35 for a 1- to 31-day supply $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply $60 for a 1- to 31-day supply 50% coinsurance for a 1- to 31-day supply3
What is a maintenance medication? Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.
When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply. A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 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. 2 For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 - individual, $5,500 - family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.
Full monthly premium*
Premium with min. state/ district contribution**
$367
+Spouse +Children +Family
Individual
Your Monthly Premium***
Full monthly premium*
Premium with min. state/ district contribution**
$142
$540
$1,035
$810
$701
$476
$1,374
$1,149
Your Monthly Premium***
Full monthly premium*
Premium with min. state/ district contribution**
$315
$782
$557
$1,327
$1,102
$1,855
$1,630
$876
$651
$1,163
$938
$1,668
$1,443
$2,194
$1,969
Your Monthly Premium***
* If you are not eligible for the state/district subsidy, you will pay the full monthly premium. Please contact your Benefits Administrator for your monthly premium. ** The premium after state, $75 and district, $150 contribution is the maximum you pay per month. Ask your Benefits Administrator for your monthly cost. (This is the amount you will owe each month after all available subsidies are applied to your premium.) *** Completed by your benefits administrator. The state/district contribution may be greater than $225. 13
MDLIVE YOUR BENEFITS PACKAGE
Telehealth
PLAY VIDEO
About this Benefit Telehealth provides 24/7/365 access to boardcertified 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.
75%
of all doctor, urgent care, and ER visits could be handled safely and effectively via telehealth.
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 14 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
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!
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? $10 Covers you, your spouse, and children up to age 26, 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
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.
Scan with your smartphone to get the app.
Call us at (888) 365-1663 or visit us at www.consultmdlive.com
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 15 abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/terms-of-use/ 010113
AVESIS YOUR BENEFITS PACKAGE
Medical Gap Plan
PLAY VIDEO
About this Benefit Medical Gap Insurance 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.
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 16 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Medical Gap Plan $4,000 - $2,500 Plan
$1,000 Plan
Plan Details:
Plan Details:
This plan covers up to:
This plan covers up to:
$4,000 In Hospital Confinement
$1,000 In Hospital Confinement
expenses associated with deductible, co-pay and coinsurance amounts not covered by your Major Medical plan.
expenses associated with deductible, co-pay and coinsurance amounts not covered by your Major Medical plan.
$2,500 Outpatient
$1,000 Outpatient
expenses associated with deductible, co-pay and coinsurance amounts not covered by your Major Medical plan.
expenses associated with deductible, co-pay and coinsurance amounts not covered by your Major Medical plan.
$4,000 Hospital Confinement Benefit
$4,000 Hospital Confinement Benefit
Monthly Rate Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family
Under Age 40: $47.72 $85.90 $116.07 $154.20
Ages 40-49 Insured Only Insured & Spouse Insured & Child(ren) Insured & Family
Insured Only Insured & Spouse Insured & Child(ren) Insured & Family
$22.62 $40.72 $54.71 $72.78
Ages 40-49 $60.36 $108.76 $120.62 $168.85
Ages 50 & Above Insured Only Insured & Spouse Insured & Child(ren) Insured & Family
Monthly Rate
Insured Only Insured & Spouse Insured & Child(ren) Insured & Family
$28.69 $51.57 $56.98 $79.92
Ages 50 & Above $123.55 $222.32 $215.39 $314.11
Inpatient Services SecureADVANTAGE pays covered expenses for: • In-Patient Hospital stays • In-Patient Surgeries • In-Patient Tests, Procedures, and Medications (billed through the facility) • Physician In-Hospital charges • Emergency Room treatment for Injuries and Sickness (sickness must result in hospital confinement within 24 hours of ER treatment)
Outpatient Services SecureADVANTAGE pays covered expenses including but not limited to: • Hospital Emergency Room Treatment for Injury or Sickness • Outpatient surgery in an outpatient Surgical Facility, Emergency Facility or Physician’s Office • Diagnostic Testing including Xrays, Diagnostic Lab, MRI’s and CT scans • Outpatient Chemotherapy or Radiation Therapy Physical Therapy or Chiropractic Care
Outpatient Benefits The Outpatient I Benefit pays on a per person per Sickness or Injury basis, up to a maximum of four "occurrences" per family per calendar year. This maximum applies to the entire family unit, regardless of the number of covered persons within the family unit. An "occurrence" is
Insured Only Insured & Spouse Insured & Child(ren) Insured & Family
$60.75 $109.33 $103.90 $152.42
the treatment, or series of treatments, for a specific Sickness or Injury. All expenses related to the treatment of the same related Sickness or Injury will accrue toward the outpatient maximum for one occurrence, regardless of whether such treatment is received in more than one calendar year period. If, however, a Covered Person is treatment-free, at any time, for at least 90 consecutive days, they may qualify for an additional outpatient maximum benefit if the family maximum per calendar year has not been met.
Secure Advantage Outpatient Benefits I pays for covered expenses including but not limited to : • Hospital Emergency Room Treatment for Injury or Sickness • Outpatient Surgery in an outpatient surgical facility, emergency facility or physician’s office • Diagnostic testing including but not limited to Xrays, diagnostic lab, MRI’s and CT scans • Outpatient chemotherapy or radiation therapy • Physical therapy or chiropractic care All Inpatient and Outpatient Benefits are limited to those expenses that are medically necessary for the treatment of an Injury or Sickness. Further, such expenses must be covered under the major medical comprehensive policy and applied to that plans deductible, copayment, or coinsurance provision. 17
CIGNA
HUMANA
Dental
Discount Dental
YOUR BENEFITS PACKAGE
PLAY VIDEO
About this Benefit 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.
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.
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 18 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Cigna Dental - Base Plan Benefits Network Plan Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**
Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $1,000
$1,000
$50 per person $150 per family
$50 per person $150 per family
Based on Reduced Contracted Fees
Maximum Allowable Charge (In-network fee level)
Plan Pays
You Pay
Plan Pays
You Pay
Class I - Diagnostic & Preventive Care Oral Evaluations Prophylaxis: routine leanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Emergency Care to Relieve Pain
100%
No Charge
100%
No Charge
Class II - Basic Restorative Care Restorative: fillings Oral Surgery – minor and major Anesthesia: general and IV sedation Repairs: Dentures Space Maintainers: non-orthodontic
80%*
20%*
80%*
20%*
Class III - Major Restorative Care Inlays / Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel/resin Crowns: permanent cast and porcelain Bridges & Dentures Endodontics: minor and major Periodontics: minor and major Repairs: Bridges, Crowns and Inlays Denture Relines, Rebases and Adjustments
50%*
50%*
50%*
50%*
50%
50% $1,000 Dependent children to age 19
50%
Class IV - Orthodontia 12 Month Waiting Period Lifetime Maximum
50% $1,000 Dependent children to age 19
Monthly PPO Premiums Tier
Rate
EE Only
$27.17
EE + 1 Dep
$56.64
EE + 2 or more Dep
$87.32
Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. 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. 19
Cigna Dental - Buy-Up Plan Benefits Network Plan Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**
Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $1,250
$1,250
$50 per person $150 per family
$50 per person $150 per family
Based on Reduced Contracted Fees
80th percentile of Reasonable & Customary Allowances
Plan Pays
You Pay
Plan Pays
You Pay
Class I - Diagnostic & Preventive Care Oral Evaluations Prophylaxis: routine leanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Emergency Care to Relieve Pain Repairs: Dentures
100%
No Charge
100%
No Charge
Class II - Basic Restorative Care Restorative: fillings Endodontics: minor and major Oral Surgery – minor and major Anesthesia: general and IV sedation Space Maintainers: non-orthodontic
80%*
20%*
80%*
20%*
Class III - Major Restorative Care Inlays / Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel/resin Crowns: permanent cast and porcelain Bridges & Dentures Periodontics: minor and major Repairs: Bridges, Crowns and Inlays Denture Relines, Rebases and Adjustments
50%*
50%*
50%*
50%*
50%
50% $1,000 Dependent children to age 19
50%
Class IV - Orthodontia 12 Month Waiting Period Lifetime Maximum
50% $1,000 Dependent children to age 19
Monthly PPO Premiums Tier
Rate
EE Only
$38.18
EE + 1 Dep
$80.98
EE + 2 or more Dep
$122.62
Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. 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 20 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.
Cigna Dental - Base and Buy-Up Plans Procedure
Exclusions and Limitations
Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams X-Rays (routine) X-Rays (non-routine) Model Periodontial Treatment Bridges, Crowns and Inlays Dentures and Partials Relines, Rebases Adjustments Bridge and Denture Repairs Sealants Space Maintainers Prosthesis Over Implant
50% coverage on Class III and IV for 12 months Two per Plan year Two per Plan year 1 per Plan year for people under 19 Allowed for tooth and/or gingival related biopsies only Bitewings: 2 per Plan year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Limited to posterior tooth. One treatment per tooth every 36 consecutive months up to age 14 Limited to non-Orthodontic treatment 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
Benefit Exclusions Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility at the dentist's Usual Fees. There is no coverage for: Services performed primarily for cosmetic reasons; veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars. Instruction for plaque control, oral hygiene and diet; experimental or investigational procedures and treatments; dental services that do not meet common dental standards. 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. Surgical implant of any type; bite registrations; precision or semi-precision attachments; splinting; services that are deemed to be medical services; services and supplies received from a hospital. For charges which would not have been made if the person had no insurance; for charges for unnecessary care, treatment or surgery. Charges which the person is not legally required to pay; charges in excess of the reasonable and customary allowances; 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. 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); to the extent that payment is unlawful where the person resides when the expenses are incurred; 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. 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. This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HPPOL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD58334 © 2015 Cigna 21
Humana Dental DHMO Monthly DHMO Premiums
Use your HumanaDental benefits The HumanaDental HD Series dental plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect with HumanaDental. No waiting periods No claims to file No annual maximums
Know what your plan covers After you enroll in a plan and receive your ID card, you can manage your plan information on your personal home page on www.HumanaDental.com.
You have the freedom to select any participating general dentist as your primary care dentist. To select a dental provider from our network, simply visit www.HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-342-5209. Life without claim forms! With the HumanaDental DHMO plan you pay your dentist directly, when applicable. Your primary dentist will provide all of your routine dental care and you will pay any copayment or discounted charges at the time of service. If you need a specialty dentist, you may receive up to a 25 percent discount by using certain participating specialty dentists from our network. Visit www.HumanaDental.com to find a participating specialist.
Good health starts with a healthy mouth Make dental visits a priority One of the first lines of defense in overall health is dental care. Regular dental cleanings can help manage problems throughout the body, such as heart disease, diabetes, and stroke. In fact, a healthy mouth can add 6.4 years to RealAge® life expectancy.1 The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less for your dental care doing so.
Questions? Check out www.HumanaDental.com Call 1-800-233-4013, Monday through Friday, 8 AM to 6 PM (TDD: 1-800-325-2025) For exclusions and limitations, please review the Specialty Benefits Regulatory and Technical Information Guide available at www.Disclosure.Humana.com. 1
Dr. Michael Roizen, RealAge.com 22
Tier
Rate
EE Only
$15.40
EE + 1
$30.48
Family Coverage
$54.21
Check your dental IQ anytime Log on to www.MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at www.MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.
DHMO HD205 Plan with Ortho The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. Members may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. HD plans copayments for listed procedures are applicable only at a participating general dentist. Member costs listed here are for services provided by a chosen participating primary care dentist (PCD) only. A PCD may decide that a member needs to see a contracted dental specialist. No referral is necessary to see a network specialist. Specialists services: Should members need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), they may be referred by a participating general dentist, or members can self-refer to any participating specialist. For HD plans, and benefits for procedures not listed on the schedule, members may receive up to a 25 percent discount by visiting certain participating specialists. Visit Humana.com to find a participating specialist.
Summary of services Services marked with a single asterisk (*) below also require separate payment of laboratory charges, not to exceed $200. The laboratory charges must be paid to the plan dentist in addition to any applicable copayment for the service. Appointments
Member Pays
Preventive (cont.)
Member Pays
D9310
Consultation (diagnostic service provided by dentist other than practitioner providing treatment)
$ 5.00
D1515
Space maintainer—fixed, bilateral
$ 70.00
D9430
Office visit (normal hours)
$ 0.00
D1520
Space maintainer—removable, unilateral
$ 85.00
D9440
Office visit (after regularly scheduled hours)
$ 35.00
D1525
Space maintainer—removable, bilateral
$ 90.00
Member Pays
D1550
Recementation of space maintainer
$ 10.00
D1575
Distal shoe space maintainer – fixed – unilateral (through age 14; primary teeth only)
$130.00
Diagnostic D0120
Periodic oral examination
no charge
D0140
Limited/comprehensive/detailed and extensive oral eval
no charge
D0150
Limited/comprehensive/detailed and extensive oral eval
no charge
D0160
Limited/comprehensive/detailed and extensive oral eval
no charge
D0180
Comprehensive periodontal evaluation
D0210
X-ray intraoral—complete series including bitewings
no charge
D0220
X-ray intraoral—periapical, first film
no charge
D0230
X-ray intraoral—periapical, each additional film
no charge
D0270
X-ray bitewing—single film
no charge
D2940
D0272
X-ray bitewings—two films
no charge
Resin Restorative
D0274
Bitewings—four films
no charge
D0330
Panoramic film
no charge
D0460
Pulp vitality tests
no charge
D0470
Diagnostic casts
Preventive
$ 15.00
no charge
Member Pays
Restorative D2140 D2150 D2160 D2161
D2330 D2331 D2332 D2391
Member Pays
Amalgam—one surface, primary or permanent Amalgam—two surfaces, primary or permanent Amalgam—three surfaces, primary or permanent Amalgam—four or more surfaces, primary or permanent
$ 5.00
Protective Restoration
$ 10.00
Resin based composite—one surface, anterior Resin based composite—two surfaces, anterior Resin based composite—three surfaces, anterior Resin based composite—one surface, posterior Resin based composite—two surfaces, posterior Resin based composite—three surfaces, posterior Resin based composite—four or more surfaces, posterior
$ 5.00 $ 5.00 $ 5.00
Member Pays $ 30.00 $ 40.00 $ 45.00 $ 65.00
D1110
Prophylaxis—adult, routine (once every 6 months)
no charge
D1120
Prophylaxis—child, routine (once every 6 months)
no charge
D1203
Topical application of fluoride (not including prophylaxis)—child (up to 16 years of age)
no charge
D2394
D1206
Topical fluoride varnish (for child <16)
no charge
D2510
Inlay—metallic, one surface
$ 225.00
D1330
Oral hygiene instruction
no charge
D2520
Inlay—metallic, two surfaces
$ 235.00
D1351
Sealant-per tooth
$ 10.00
D1510
Space maintainer—fixed, unilateral
$ 50.00
D2530
Inlay—metallic, three or more surfaces
$ 245.00
D2392 D2393
$ 70.00 $ 80.00 $ 120.00
23
DHMO HD205 Plan with Ortho Crown and Bridge
Member Pays
D2740* Crown—porcelain/ceramic substrate
$ 270.00
fused to high noble D2750* Crown—porcelain metal
$ 270.00
Crown—porcelain fused to predominantly base metal
$ 270.00
D2751
D2752* Crown—porcelain fused to noble metal
$ 270.00
D2790* Crown—full cast high noble metal
$ 270.00
Crown—full cast predominantly base metal
D2791
$ 270.00
Endodontics (cont.)
Member Pays
D3330
Root canal therapy—molar (excluding final restoration)
$ 250.00
D3410
Apicoectomy/periradicular surgery— anterior
$ 135.00
Periodontics (Gum Treatment)
Member Pays
D4210
Gingivectomy/gingivoplasty per quadrant
$ 120.00
D4211
Gingivectomy/gingivoplasty per tooth
$ 40.00
D4341
Periodontal scaling and root planing, per quadrant
$ 55.00
D4342
Periodontal scaling and root planing 1 to 3 teeth per quadrant
$ 50.00
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis
$ 50.00
D4381
Localized delivery of chemotherapeutic agents (per tooth)
$ 60.00
D4910
Periodontal maintenance
D2792* Crown—full cast noble metal
$ 270.00
D2910
Recement inlay
$ 15.00
D2920
Recement crown
$ 15.00
D2930
Prefabricated stainless steel crown— primary tooth
$ 75.00
D2950
Core buildup, including any pins
$ 50.00
D2951
Pin retention—per tooth, in addition to restoration
$ 15.00
D2952
Cast post and core in addition to crown
$ 95.00
D2953
Each additional cast post—same tooth
$ 100.00
Prefabricated post and core in addition to crown
D5110
Complete denture—maxillary
$ 375.00
D2954
$ 85.00
D5120
Complete denture—mandibular
$ 375.00
D2962
Labial veneer (porcelain laminate)— laboratory
$ 350.00
D5130
Immediate denture—maxillary
$ 375.00
D5140
Immediate denture—mandibular
$ 375.00
Prosthodontics (Fixed)
Member Pays
D6210* Pontic—cast high noble metal
$ 270.00
D6211
$ 270.00
Pontic—cast predominantly base metal
Prosthodontics
$ 45.00
Member Pays
D5211^ Maxillary partial denture—resin base
$ 400.00
D5212^ Mandibular partial denture—resin base
$ 400.00
D5213^ Maxillary partial denture—cast metal framework, resin denture bases
$ 425.00
D6212* Pontic—cast noble metal
$ 270.00
fused to high noble D6240* Pontic—porcelain metal
$ 270.00
D5214^ Mandibular partial denture—cast metal framework, resin denture bases
$ 425.00
Pontic—porcelain fused to predominantly base metal
$ 270.00
D5410
Adjust complete denture—maxillary
$ 15.00
$ 270.00
D5411
Adjust complete denture—mandibular
$ 15.00
D5421
Adjust partial denture—maxillary
$ 15.00
D5422
Adjust partial denture—mandibular
$ 15.00
D6241
D6242* Pontic—porcelain fused to noble metal fused to high noble D6750* Crown—porcelain metal
$ 270.00
Crown—porcelain fused to predominantly base metal
$ 270.00
D6751
Repairs to Prosthetics
Member Pays
D5511
Repair broken complete denture base
$ 35.00
D6752* Crown—porcelain fused to noble metal
$ 270.00
D6790* Crown—full cast high noble metal
$ 270.00
D5520
Replace missing or broken teeth— complete denture (each tooth)
$ 35.00
$ 270.00
D5611
Repair resin denture base, mandibular
$ 35.00
$ 270.00
D5630
Repair or replace broken clasp
$ 35.00
D5640
Replace broken teeth—per tooth
$ 35.00
D5650
Add tooth to existing partial denture
$ 35.00
D5730
Reline complete maxillary denture (chairside)
$ 60.00
Crown—full cast predominantly base metal
D6791
D6792* Crown—full cast noble metal Recement fixed partial denture (per unit)
D6930
Endodontics
$ 15.00
Member Pays
D3220
Therapeutic pulpotomy
$ 40.00
D3221
Pulpal debridement, primary and permanent teeth
$ 80.00
D5731
Reline complete mandibular denture (chairside)
$ 60.00
D3310
Root canal therapy—anterior (excluding final restoration)
$ 85.00
D5740
Reline maxillary partial denture (chairside)
$ 60.00
Root canal therapy—bicuspid (excluding final restoration)
$ 195.00
D5741
Reline mandibular partial denture (chairside)
$ 60.00
D3320
24
DHMO HD205 Plan with Ortho Repairs to Prosthetics (cont.)
Member Pays
D5750
Reline complete maxillary denture (laboratory)
$ 95.00
D5751
Reline complete mandibular denture (laboratory)
$ 95.00
D5760
Reline maxillary partial denture (laboratory)
$ 95.00
D5761
Reline mandibular partial denture (laboratory)
$ 95.00
D5850
Tissue conditioning—maxillary
$ 30.00
D5851
Tissue conditioning—mandibular
$ 30.00
Extractions/Oral & Maxillofacial Surgery
Adjunctive General Services D9110
Palliative (emergency) treatment
$ 20.00
D9450
Case presentation, detailed and extensive treatment planning
no charge
D9951
Occlusal adjustment—limited
$ 35.00
D9952
Occlusal adjustment—complete
$ 165.00
Orthodontics
D8070
Member Pays
Coronal remnants, deciduous tooth
no charge
D7140
Extraction, erupted tooth or exposed tooth
no charge
D7210
Surgical removal of erupted tooth
$ 40.00
D7220
Removal of impacted tooth—soft tissue
$ 55.00
Orthodontic treatment
D7230
Removal of impacted tooth—partially bony
$ 70.00
D7240
Removal of impacted tooth— completely bony
$ 85.00
D7250
Surgical removal of residual tooth roots
$ 40.00
Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
D7310
Alveoloplasty in conjunction with extractions—per quadrant
$ 35.00
D7311
Alveoplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant
$ 15.00
D7320
Alveoloplasty not in conjunction with extractions—per quadrant
$ 75.00
D7321
Alveoplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant
$ 30.00
D7510
Incision and drainage of abscess— intraoral
$ 35.00
D9215
Local anesthesia
D9230
Analgesia (nitrous oxide), per 15 minutes
Consultation
D8080
$ 45.00
Records/treatment planning
$ 250.00
$ 15.00
Records/treatment planning
$ 250.00 $ 1,900.00
Comprehensive orthodontic treatment of the adult dentition; Adult 19 years of age and over; Up to 24 months of routine orthodontic treatment for Class I and Class II cases no charge
Evaluation
$ 45.00
Records/treatment planning
$ 250.00
Orthodontic treatment D8680
no charge $ 45.00
Consultation
no charge
$ 1,900.00
Evaluation
Orthodontic treatment
Member Pays
no charge
Evaluation
Consultation
D8090
Member Pays
Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
D7111
Anesthesia
Member Pays
Retention
$ 1,900.00 $ 455.00
*The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal. The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal. ^ Including any conventional clasps, rests, and teeth. Note: Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services.
Unlisted procedures are available at certain participating dentists usual fee less 25%. Visit www.HumanaDental.com to find a participating dentist who offers the discount on non-covered services. When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional $50 per unit. If you break your appointment with your dentist without 24-hour advance notice, you will be subject to your dentist’s broken appointment fee. Additional exclusions and limitations are listed along with full plan information in your certificate of benefits. 25
SUPERIOR VISION YOUR BENEFITS PACKAGE
Vision
PLAY VIDEO
About this Benefit 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.
75% of U.S. residents between age 25 and 64 require some sort of vision correction.
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 26 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Vision Benefits Exam Frames Contact Lenses1
In-Network
Out-of-Network
Covered in full $150 retail allowance $150 retail allowance
Up to $35 retail Up to $70 retail Up to $80 retail
Covered in full
Up to $150 retail
Medically Necessary Contact Lenses Lasik Vision Correction
$200 allowance2
Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Lenticular Polycarbonate UV coating Scratch coating
Covered in full Covered in full Covered in full See description3 Covered in full Covered in full Covered in full Covered in full
Up to $25 retail Up to $40 retail Up to $45 retail Up to $45 retail Up to $80 retail Up to $20 retail Up to $20 retail Up to $25 retail
Monthly Premiums EE only EE + 1 dependent EE + Family
$9.25 $15.75 $20.10
Co-Pays Exam Materials
$10 $25
Services/Frequency Exam Frame Lenses Contact Lenses
12 months 12 months 12 months 12 months
(Based on date of service)
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 1
Contact lenses and related professional services (fitting, evaluation and followup) are covered in lieu of eyeglass lenses and frames benefit. 2 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.
Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy. 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
SuperiorVision.com Customer Service 800.507.3800
27
THE HARTFORD YOUR BENEFITS PACKAGE
Disability
PLAY VIDEO
About this Benefit 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.
Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.
34.6 months is the duration of the average disability claim.
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 28 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Long Term Disability Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. For specific details on how benefits are paid, refer to carrier brochure. Your disability coverage amount and premium can be accessed during your enrollment.
Pre-existing Conditions
Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks.
Benefit Reductions Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as: Social Security Disability Insurance (please see www.mybenefitshub.com/alamoheightsisd for exceptions) Workers' Compensation Other employer-based Insurance coverage you may have Unemployment benefits Settlements or judgments for income loss Retirement benefits that your employer fully or partially pays for (such as a pension plan.)
Mental Illness, Alcoholism and Substance Abuse
Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: War or act of war (declared or not) Military service for any country engaged in war or other armed conflict The commission of, or attempt to commit a felony An intentionally self-inflicted injury
You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.
What other benefits are included in my disability coverage?
Your benefit payments will not be reduced by certain kinds of other income, such as: Retirement benefits if you were already receiving them before you became disabled Retirement benefits that are funded by your after-tax contributions Your personal savings, investment, IRAs or Keoghs Profit-sharing Most personal disability policies Social Security increases Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.
Any case where your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits
Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment. Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit. Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services. The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services. Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived. Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims. 29
Long Term Disability Premium Option: For the Premium benefit option â&#x20AC;&#x201C; the table below applies to disabilities resulting from injury or sickness: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older
Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600
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Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800
Benefits Payable To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months
MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Monthly Benefit 0/3 14 / 14 30 / 30 60 / 60 90 / 90 $200 $8.98 $6.86 $6.02 $3.28 $2.46 $13.47 $10.29 $9.03 $4.92 $3.69 $300 $17.96 $13.72 $12.04 $6.56 $4.92 $400 $22.45 $17.15 $15.05 $8.20 $6.15 $500 $26.94 $20.58 $18.06 $9.84 $7.38 $600 $31.43 $24.01 $21.07 $11.48 $8.61 $700 $35.92 $27.44 $24.08 $13.12 $9.84 $800 $40.41 $30.87 $27.09 $14.76 $11.07 $900 $44.90 $34.30 $30.10 $16.40 $12.30 $1,000 $49.39 $37.73 $33.11 $18.04 $13.53 $1,100 $1,200 $53.88 $41.16 $36.12 $19.68 $14.76 $58.37 $44.59 $39.13 $21.32 $15.99 $1,300 $62.86 $48.02 $42.14 $22.96 $17.22 $1,400 $67.35 $51.45 $45.15 $24.60 $18.45 $1,500 $71.84 $54.88 $48.16 $26.24 $19.68 $1,600 $1,700 $76.33 $58.31 $51.17 $27.88 $20.91 $80.82 $61.74 $54.18 $29.52 $22.14 $1,800 $85.31 $65.17 $57.19 $31.16 $23.37 $1,900 $89.80 $68.60 $60.20 $32.80 $24.60 $2,000 $94.29 $72.03 $63.21 $34.44 $25.83 $2,100 $2,200 $98.78 $75.46 $66.22 $36.08 $27.06 $103.27 $78.89 $69.23 $37.72 $28.29 $2,300 $107.76 $82.32 $72.24 $39.36 $29.52 $2,400 $112.25 $85.75 $75.25 $41.00 $30.75 $2,500 $116.74 $89.18 $78.26 $42.64 $31.98 $2,600 $2,700 $121.23 $92.61 $81.27 $44.28 $33.21 $125.72 $96.04 $84.28 $45.92 $34.44 $2,800 $130.21 $99.47 $87.29 $47.56 $35.67 $2,900 $134.70 $102.90 $90.30 $49.20 $36.90 $3,000 $139.19 $106.33 $93.31 $50.84 $38.13 $3,100 $143.68 $109.76 $96.32 $52.48 $39.36 $3,200
Long Term Disability
Annual Earnings $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000
Monthly Earnings $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650 $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250
MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Monthly Benefit 0/3 14 / 14 30 / 30 60 / 60 90 / 90 $148.17 $113.19 $99.33 $54.12 $40.59 $3,300 $152.66 $116.62 $102.34 $55.76 $41.82 $3,400 $157.15 $120.05 $105.35 $57.40 $43.05 $3,500 $161.64 $123.48 $108.36 $59.04 $44.28 $3,600 $3,700 $166.13 $126.91 $111.37 $60.68 $45.51 $170.62 $130.34 $114.38 $62.32 $46.74 $3,800 $175.11 $133.77 $117.39 $63.96 $47.97 $3,900 $179.60 $137.20 $120.40 $65.60 $49.20 $4,000 $184.09 $140.63 $123.41 $67.24 $50.43 $4,100 $4,200 $188.58 $144.06 $126.42 $68.88 $51.66 $193.07 $147.49 $129.43 $70.52 $52.89 $4,300 $197.56 $150.92 $132.44 $72.16 $54.12 $4,400 $202.05 $154.35 $135.45 $73.80 $55.35 $4,500 $206.54 $157.78 $138.46 $75.44 $56.58 $4,600 $4,700 $211.03 $161.21 $141.47 $77.08 $57.81 $215.52 $164.64 $144.48 $78.72 $59.04 $4,800 $220.01 $168.07 $147.49 $80.36 $60.27 $4,900 $224.50 $171.50 $150.50 $82.00 $61.50 $5,000 $228.99 $174.93 $153.51 $83.64 $62.73 $5,100 $5,200 $233.48 $178.36 $156.52 $85.28 $63.96 $237.97 $181.79 $159.53 $86.92 $65.19 $5,300 $242.46 $185.22 $162.54 $88.56 $66.42 $5,400 $246.95 $188.65 $165.55 $90.20 $67.65 $5,500 $251.44 $192.08 $168.56 $91.84 $68.88 $5,600 $255.93 $195.51 $171.57 $93.48 $70.11 $5,700 $260.42 $198.94 $174.58 $95.12 $71.34 $5,800 $264.91 $202.37 $177.59 $96.76 $72.57 $5,900 $269.40 $205.80 $180.60 $98.40 $73.80 $6,000 $273.89 $209.23 $183.61 $100.04 $75.03 $6,100 $6,200 $278.38 $212.66 $186.62 $101.68 $76.26 $282.87 $216.09 $189.63 $103.32 $77.49 $6,300 $287.36 $219.52 $192.64 $104.96 $78.72 $6,400 $291.85 $222.95 $195.65 $106.60 $79.95 $6,500 $296.34 $226.38 $198.66 $108.24 $81.18 $6,600 $300.83 $229.81 $201.67 $109.88 $82.41 $6,700 $305.32 $233.24 $204.68 $111.52 $83.64 $6,800 $309.81 $236.67 $207.69 $113.16 $84.87 $6,900 $314.30 $240.10 $210.70 $114.80 $86.10 $7,000 $318.79 $243.53 $213.71 $116.44 $87.33 $7,100 $7,200 $323.28 $246.96 $216.72 $118.08 $88.56 $327.77 $250.39 $219.73 $119.72 $89.79 $7,300 $332.26 $253.82 $222.74 $121.36 $91.02 $7,400 $336.75 $257.25 $225.75 $123.00 $92.25 $7,500
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Long Term Disability Select Option: For the Select benefit option â&#x20AC;&#x201C; see the tables below for the applicable benefit duration based on whether your disability is a result of injury or sickness. Schedule for disability caused by injury: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older
Benefits Payable To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months
Schedule for disability caused by sickness: Age Disabled Prior to Age 65 Age 65 to 69 Age 69 and older
Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000
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Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500
Benefits Payable 3 Years To Age 70, but not less than one year 1 Year MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Monthly Benefit 0/3 14 / 14 30 / 30 60 / 60 90 / 90 $200 $8.70 $6.60 $5.76 $2.66 $2.02 $300 $13.05 $9.90 $8.64 $3.99 $3.03 $17.40 $13.20 $11.52 $5.32 $4.04 $400 $500 $21.75 $16.50 $14.40 $6.65 $5.05 $600 $26.10 $19.80 $17.28 $7.98 $6.06 $700 $30.45 $23.10 $20.16 $9.31 $7.07 $800 $34.80 $26.40 $23.04 $10.64 $8.08 $900 $39.15 $29.70 $25.92 $11.97 $9.09 $1,000 $43.50 $33.00 $28.80 $13.30 $10.10 $1,100 $47.85 $36.30 $31.68 $14.63 $11.11 $1,200 $52.20 $39.60 $34.56 $15.96 $12.12 $56.55 $42.90 $37.44 $17.29 $13.13 $1,300 $1,400 $60.90 $46.20 $40.32 $18.62 $14.14 $1,500 $65.25 $49.50 $43.20 $19.95 $15.15 $69.60 $52.80 $46.08 $21.28 $16.16 $1,600 $1,700 $73.95 $56.10 $48.96 $22.61 $17.17 $1,800 $78.30 $59.40 $51.84 $23.94 $18.18 $1,900 $82.65 $62.70 $54.72 $25.27 $19.19 $2,000 $87.00 $66.00 $57.60 $26.60 $20.20 $2,100 $91.35 $69.30 $60.48 $27.93 $21.21 $2,200 $95.70 $72.60 $63.36 $29.26 $22.22 $2,300 $100.05 $75.90 $66.24 $30.59 $23.23 $2,400 $104.40 $79.20 $69.12 $31.92 $24.24 $108.75 $82.50 $72.00 $33.25 $25.25 $2,500 $2,600 $113.10 $85.80 $74.88 $34.58 $26.26 $2,700 $117.45 $89.10 $77.76 $35.91 $27.27 $121.80 $92.40 $80.64 $37.24 $28.28 $2,800 $2,900 $126.15 $95.70 $83.52 $38.57 $29.29 $130.50 $99.00 $86.40 $39.90 $30.30 $3,000
Long Term Disability
Annual Earnings $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000
Monthly Earnings $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650 $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250
MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Monthly Benefit 0/3 14 / 14 30 / 30 60 / 60 90 / 90 $3,100 $134.85 $102.30 $89.28 $41.23 $31.31 $3,200 $139.20 $105.60 $92.16 $42.56 $32.32 $3,300 $143.55 $108.90 $95.04 $43.89 $33.33 $3,400 $147.90 $112.20 $97.92 $45.22 $34.34 $3,500 $152.25 $115.50 $100.80 $46.55 $35.35 $3,600 $156.60 $118.80 $103.68 $47.88 $36.36 $160.95 $122.10 $106.56 $49.21 $37.37 $3,700 $3,800 $165.30 $125.40 $109.44 $50.54 $38.38 $3,900 $169.65 $128.70 $112.32 $51.87 $39.39 $174.00 $132.00 $115.20 $53.20 $40.40 $4,000 $4,100 $178.35 $135.30 $118.08 $54.53 $41.41 $4,200 $182.70 $138.60 $120.96 $55.86 $42.42 $4,300 $187.05 $141.90 $123.84 $57.19 $43.43 $4,400 $191.40 $145.20 $126.72 $58.52 $44.44 $4,500 $195.75 $148.50 $129.60 $59.85 $45.45 $4,600 $200.10 $151.80 $132.48 $61.18 $46.46 $4,700 $204.45 $155.10 $135.36 $62.51 $47.47 $4,800 $208.80 $158.40 $138.24 $63.84 $48.48 $213.15 $161.70 $141.12 $65.17 $49.49 $4,900 $5,000 $217.50 $165.00 $144.00 $66.50 $50.50 $5,100 $221.85 $168.30 $146.88 $67.83 $51.51 $226.20 $171.60 $149.76 $69.16 $52.52 $5,200 $5,300 $230.55 $174.90 $152.64 $70.49 $53.53 $5,400 $234.90 $178.20 $155.52 $71.82 $54.54 $5,500 $239.25 $181.50 $158.40 $73.15 $55.55 $5,600 $243.60 $184.80 $161.28 $74.48 $56.56 $5,700 $247.95 $188.10 $164.16 $75.81 $57.57 $5,800 $252.30 $191.40 $167.04 $77.14 $58.58 $5,900 $256.65 $194.70 $169.92 $78.47 $59.59 $6,000 $261.00 $198.00 $172.80 $79.80 $60.60 $265.35 $201.30 $175.68 $81.13 $61.61 $6,100 $6,200 $269.70 $204.60 $178.56 $82.46 $62.62 $6,300 $274.05 $207.90 $181.44 $83.79 $63.63 $278.40 $211.20 $184.32 $85.12 $64.64 $6,400 $6,500 $282.75 $214.50 $187.20 $86.45 $65.65 $6,600 $287.10 $217.80 $190.08 $87.78 $66.66 $6,700 $291.45 $221.10 $192.96 $89.11 $67.67 $6,800 $295.80 $224.40 $195.84 $90.44 $68.68 $6,900 $300.15 $227.70 $198.72 $91.77 $69.69 $7,000 $304.50 $231.00 $201.60 $93.10 $70.70 $7,100 $308.85 $234.30 $204.48 $94.43 $71.71 $7,200 $313.20 $237.60 $207.36 $95.76 $72.72 $7,300 $317.55 $240.90 $210.24 $97.09 $73.73 $321.90 $244.20 $213.12 $98.42 $74.74 $7,400 $326.25 $247.50 $216.00 $99.75 $75.75 $7,500
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HUMANA
Cancer
YOUR BENEFITS PACKAGE
PLAY VIDEO
About this Benefit 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.
Breast Cancer is the most commonly diagnosed cancer in women.
If caught early, prostate cancer is one of the most treatable malignancies.
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 34 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Cancer Plan Features
Donor Benefits Wellness Benefits Many Benefits have no Lifetime Maximum Covers Certain Lodging and Transportation
Portable (take it with You) In and Out of Hospital benefits Pays regardless of other coverage
Benefit
Low
High
Wellness Benefit. For Cancer screening tests such as mammogram, flexible sigmoidoscopy, pap smear, chest X-ray, hemocult stool specimen, or prostate screen. No Lifetime Maximum
Up to $50 per calendar year
Up to $50 per calendar year
Positive Diagnosis Test. Payable for a test that leads to positive diagnosis of Cancer or Specified Disease within 90 days. This benefit is not payable if the same Cancer or Specified Disease recurs.
Up to $300 per calendar year
Up to $300 per calendar year
First Diagnosis Benefit. One-time benefit payable when a Covered Person is first diagnosed with Cancer (other than Skin Cancer) or a Specified Disease. Must occur after the Certificate Effective Date.
$2,500
$2,500
Up to $75 per day for lodging. 50 cents per mile if a personal vehicle is used.
Up to $75 per day for lodging. 50 cents per mile if a personal vehicle is used.
Up to $1,500
Up to $3,000
Adult Companion Lodging and Transportation. Payable for one adult companion to stay with a Covered Person who is confined in a Hospital that is more than 60 miles and less than 700 miles from his or her home. Covered expenses include a single room in a motel or hotel up to 60 days per confinement; and the actual charge of round trip coach fare by a common carrier or a mileage allowance for the use of a personal vehicle. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. No Lifetime Maximum Surgery. Covers actual surgeon’s fee for an operation up to the amount listed on the schedule. Benefits for surgery performed on an outpatient basis will be 150% of the schedule benefit amount, not to exceed the actual surgeon’s fees. No Lifetime Maximum Bone Marrow and Stem Cell Transplant. We will pay Actual Charges per Covered Person for surgical and anesthetic charges associated with bone marrow transplant and/or peripheral stem cell transplant
Actual charges to a Actual charges to a combined lifetime combined lifetime maximum of $15,000 maximum of $15,000
Anesthesia. For services of an anesthesiologist during a Covered Person’s surgery. No Lifetime Maximum
Up to 25% of surgical Up to 25% of surgical benefit paid. benefit paid. $100 maximum per $100 maximum per Covered Person Covered Person
Radiation, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy. Covers treatment administered by a Radiologist, Chemotherapist or Oncologist on an inpatient or outpatient basis. No Lifetime Maximum
Actual charges up to $500 per day
Actual charges up to $1,000 per day
Up to $7,500 per calendar year
Up to $7,500 per calendar year
New or Experimental Treatment. We will pay the expenses incurred by a Covered Person for New or Experimental Treatment judged necessary by the attending Physician and received in the United States or in its territories. No Lifetime Maximum
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Cancer Other Specified Diseases Covered
Amyotrophic Lateral Sclerosis Cystic Fibrosis Encephalitis Hansen’s Disease Legionnaire’s Disease Lupus Erythematosus Lyme Disease Malaria
Meningitis (epidemic cerebrospinal) Muscular Dystrophy Myasthenia Gravis Niemann-Pick Disease Osteomyelitis Poliomyelitis Rabies Reye’s Syndrome Rheumatic Fever Rocky Mountain Spotted Fever
Scarlet Fever Tay-Sachs Disease Tetanus Toxic Epidermal Necrolysis Tuberculosis Tularemia
Whipple’s Disease
Payment of Benefits
Covered Persons
Benefits are payable for a Covered Person’s Positive Diagnosis of a Cancer or Specified Disease that begins after the Certificate Effective Date and while this Certificate has remained in force.
Covered Person means any of the following: a. the Named Insured; or b. any eligible Spouse or Child, as defined and as indicated on the Certificate Schedule whose coverage has become effective; c. any eligible Spouse or Child, as defined and added to this Certificate by endorsement after the Certificate Effective Date whose coverage has become effective; or d. a newborn child (as described in the Eligibility Section).
See brochure for additional coverage, exclusions and limitations.
Termination of Coverage A Covered Person’s insurance under the Policy will automatically terminate on the earliest of the following dates: 1. 2.
3. 4. 5.
6.
the date that the Policy terminates. the date of termination of any section or part of the Policy with respect to insurance under such section or part. the date the Policy is amended to terminate the eligibility of the Employee class. any premium due date, if premium remains unpaid by the end of the grace period. the premium due date coinciding with or next following the date the Covered Person ceases to be a member of an eligible class. the date the Policyholder no longer meets participation requirements.
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Child (Children) means the Named Insured’s unmarried child, including a natural child from the moment of birth, stepchild, foster or legally adopted child, or child in the process of adoption (including a child while the Named Insured is a party to a proceeding in which the adoption of such child by the Named Insured is sought); a child for whom the Named Insured is required by a court order to provide medical support, and grandchildren who are dependent on the Named Insured for federal income tax purposes at the time of application, who is: a. not yet age 25; or b. not yet age 26 if a full time student at an accredited school.
Cancer Option To Add Additional Benefits Hospital Intensive Care Insurance Rider Form Number HIC-GP-ICR 6/09 In consideration of additional premium, this coverage will provide you with benefits if you go into a Hospital Intensive Care Unit (ICU).
Benefits Your benefits start the first day you go into ICU. The benefit is payable for up to 45 days per ICU stay.
Group Cancer Rate—Monthly Rates Base Policy Coverage Tier
Low
High
Individual
$18.38
$23.87
Individual + Spouse
$37.60
$48.84
Individual + Child(ren)
$24.43
$31.25
Family
$43.66
$56.23
Hospital Intensive Care Confinement Benefit You may choose the benefit of $325 or $625 per day. It is reduced by one-half at age 75.
Double Benefits We will double the daily benefits for each day you are in an ICU as a result of Cancer or a Specified Disease. We will also double the benefit for an injury that results from: being struck by an automobile, bus, truck, motorcycle, train, or airplane; or being involved in an accident in which the named insured was the operator or was a passenger in such vehicle. ICU confinement must occur within 48 hours of the accident.
Emergency Hospitalization and Subsequent Transfer to an ICU We will pay the benefit selected by you for the highest level of care in a hospital that does not have an ICU, if you are admitted on an emergency basis, and you are transferred within 48 hours to the ICU of another Hospital.
Step Down Unit We will pay a benefit equal to one half the chosen daily benefit for confinement in a Step Down Unit.
Variable Benefit Elections Benefit Low High Hospital Confinement $100 $100 Surgical $1,500 $3,000 Radiation/ $500 per day $1,000 per day Chemotherapy First Diagnosis $2,500 $2,500 Colony Stimulating $1,500 per month $3,000 per month Factors Wellness $50 $50
Optional Intensive Care Rider Coverage Tier
$325 per day
$625 per day
Individual
$2.62
$5.04
Individual + Spouse
$5.45
$10.48
Individual + Child(ren)
$4.17
$8.02
Family
$7.00
$13.46
Exceptions and Other Limitations Except as provided in Step Down Unit and Emergency Hospitalization and Subsequent Transfer to an ICU, coverage does not provide benefits for: surgical recovery rooms; progressive care; intermediate care; private monitored rooms; observation units; telemetry units; or other facilities which do not meet the standards for a Hospital Intensive Care Unit. Benefits are not payable: if you go into an ICU before the Certificate Effective Date; if you go into an ICU for intentionally self-inflicted bodily injury or suicide attempts; if you go into an ICU due to being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on the advice of a Physician and taken according to the Physician’s instructions. The term “intoxicated” refers to that condition as defined by law in the jurisdiction where the accident or cause of loss occurred.
Underwritten by: Humana Insurance Company
See the Medicare Supplement Buyer’s Guide available from the Company. This policy only covers cancer and the diseases specified above. Upon receipt of your policy, please review it and your application. If any information is incorrect, please contact us. P.O. Box 161690 | Austin, Texas 78716 | 1-800-845-7519
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HUMANA YOUR BENEFITS PACKAGE
Accident
PLAY VIDEO
About this Benefit
2/3
Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-soserious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.
of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or
usually live paycheck to paycheck.
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 38 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Accident Plan Features
Benefits For:
On and off the job benefits Pays regardless of other coverage Portable (take it with You)
Accident Medical Expense Benefit Accident Hospital Indemnity Dislocations and Fractures Accidental Death and Dismemberment
Benefit Accident Medical Expense Benefit We will pay the Actual Charge incurred up to $250 per unit if, as a result of Injury, a Covered Person requires medical or surgical treatment. Accident Hospital Indemnity Benefit We will pay for each day a Covered Person is Confined during one or more periods of Hospital Confinement if: a) the Confinement is due to Injury b) the first day of Confinement occurs within 90 days after the accident. Ambulance Service Benefit We will pay for regular ambulance service and for air Ambulance if as a result of an injury, a Covered Person requires ambulance service for transfer; a) to a Hospital; or b) from a Hospital
Bronze 1 Unit
Silver 2 Units
Gold 3 Units
$250
$500
$750
$100
$200
$300
Regular Ambulance / Air Ambulance $100 / $200
$200 / $400
$300 / $600
For Loss of:
Bronze (1 Unit)
Silver (2 Units)
Gold (3 Units)
Life Both Hands or Both Feet or Sight of Both Eyes Both Arms or Both Legs One Hand or Arm and One Foot or Leg Sight of One Eye One Hand or One Arm One Foot or One Leg One or More Entire Toes One or More Entire Fingers
$20,000 $20,000 $20,000 $20,000 $10,000 $10,000 $10,000 $1,000 $800
$40,000 $40,000 $40,000 $40,000 $20,000 $20,000 $20,000 $2,000 $1,600
$60,000 $60,000 $60,000 $60,000 $30,000 $30,000 $30,000 $3,000 $2,400
Accidental Death and Dismemberment Benefit We will pay the following amount shown based on Your Selection of coverage:
Primary Insured Coverage 100%/Spouse Coverage 50%/ Child Coverage 25% Loss means with regard to: a) hands and feet--actual severance through or above wrist or ankle joints; b) sight, entire and irrecoverable loss thereof; c) toes and fingers--actual severance through or above the metacarpophalangeal joints. If loss is sustained by a Covered Person while riding as a fare-paying passenger on a scheduled Common Carrier, We will pay three times the amount payable under the Accidental Death and Dismemberment Benefit.
Monthly Rates Coverage Tier Individual Individual + Spouse Individual + Child(ren) Family
Base Policy Bronze Level $9.40 $16.82 $17.46 $24.89
Base Policy Silver Level $18.80 $33.64 $34.92 $49.78
Base Policy Gold Level $28.20 $50.46 $52.38 $74.67
Additional Benefit Rider $3.29 $6.57 $7.36 $10.64 39
Accident Exclusions and Limitations
Pre-Existing Condition Limitation
No Benefits are payable when a Covered Person’s loss is caused or contributed to by: suicide, while sane or insane, or attempted suicide; intentionally self-inflicted Injury; any act of war whether or not declared; participation in a riot, or insurrection; Injury sustained while on full-time active duty (other than for two (2) months or less training) in any military, naval or air force. When the Employee gives Us written notice, any unearned Premium will be refunded prorata for any period not covered by the Policy due to this exclusion; Injury occurring prior to the Employee’s start date of insurance; Injury while engaged in an illegal activity; aviation, except flight in a regularly scheduled passenger aircraft; being intoxicated as established by the laws of his or her state of residence; the voluntary taking of any sedative, drug, alcohol, poison or inhalation of any gas unless taken as prescribed or administered by a physician; participation in a felony; dental care or treatment unless caused by Injury to natural teeth; all Sicknesses including pregnancy, illness, mental illness or emotional disorders, bodily infirmity, rest cure, convalescent care or rehabilitation. Complications of Pregnancy that are the result of accidental Injury are covered; Injury while sky diving, hang gliding, parachuting, bungee jumping, rock climbing, ballooning or scuba diving; driving in any race or speed test or while testing an automobile or vehicle on any racetrack or speedway; services received in an emergency room, unless required because of emergency treatment; participating in or practicing for any semi-professional or professional competitive athletic contest in which any compensation is received; hernia, carpal tunnel syndrome or any complication therefrom; any bacterial infection (except pyogenic infections which shall occur with and through an accidental cut or wound).
Pre-existing Condition means a condition which a Physician has treated or for which a Physician has advised treatment of the Covered Person within 12 months before the Covered Person’s Effective Date. It is also one which would cause a person to seek diagnosis or care within the same 12-month period.
No Benefits of the Policy will be paid for loss that takes place outside of the United States.
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Losses that occur after the Pre-existing Condition provision has been satisfied will be covered for an Injury that occurred before the date the person becomes a Covered Person under the Policy unless the Injury has been specifically excluded by name or description within the Policy or Rider.
Covered Persons Covered Person means: a) You; and b) each person named as Your Dependent in the Enrollment Form Child (Children) means a person who is primarily dependent upon and living with the Insured in a permanent parent-child relationship and a: natural or adopted child of the Insured or Spouse; Child placed with the Insured or Spouse for adoption; Child legally placed with the Insured or Spouse as a foster Child; or stepchild of the Insured. Child does not include a: person not meeting the above Child definition; Child living outside of the United States (unless living with an Insured); or Child on active military duty for a period in excess of 30 days.
Termination of Coverage A Covered Person’s insurance under the Group Policy will automatically terminate on the earliest of the following dates: a. the date that the Group Policy terminates. b. the date the Group Policy is amended to terminate the eligibility of the Employee class. c. the last day of the grace period, if premium remains unpaid by the end of the grace period. d. the premium due date coinciding with or next following the date the Employee ceases to be a member of an eligible class; e. the date of death of the Employee f. the date of attainment of the Group Policy Age Limit as shown in the Schedule of Benefits
Accident Dependent Termination: A Dependentâ&#x20AC;&#x2122;s coverage will end: a. with respect to a covered Spouse, on the date he or she is divorced from the Primary Covered Person; b. on the date the primary Covered Person dies; c. on the date the required premium for the Dependentâ&#x20AC;&#x2122;s coverage is not paid; d. with respect to a covered Dependent, first of the month following the date the Dependent is a member of an eligible Class; or e. on the date the Primary Covered Person reaches the Policy Age Limit noted on the Insuring Information page.
Portability On the date the Policy terminates or the date the Named Insured ceases to be a member of an eligible class, Named Insureds and their covered dependents will be eligible to exercise the portability privilege. Portability coverage may continue beyond the termination date of the Policy, subject to the timely payment of premiums. Portability coverage will be effective on the day after insurance under the Policy terminates. The benefits, terms and conditions of the portability coverage will be the same as those provided under the Policy when the insurance terminated. The initial portability premium rate is the rate in effect under the Policy for active employees who have the same coverage. The premium rate for portability coverage may change for the class of Covered Persons on portability on any premium due date.
41
AFLAC
Critical Illness
YOUR BENEFITS PACKAGE
PLAY VIDEO
About this Benefit 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.
$16,500 Is the aggregate cost of a hospital stay for a heart attack.
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 42 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Critical Illness COVERED CRITICAL ILLNESSES CANCER (Internal or Invasive)
100%
HEART ATTACK (Myocardial Infarction)
100%
STROKE (Apoplexy or Cerebral Vascular Accident)
100%
MAJOR ORGAN TRANSPLANT
100%
END-STAGE RENAL FAILURE
100%
CARCINOMA IN SITU (Payment of this benefit will reduce your benefit for cancer by 25%.)
25%
CORONARY ARTERY BYPASS SURGERY (Payment of this benefit will reduce your benefit for heart attack by 25%.)
25%
FIRST OCCURRENCE BENEFIT A lump sum benefit is payable upon initial diagnosis of a covered critical illness. Employee benefit amounts are available from $10,000 to $20,000. Spouse coverage is also available in benefit amounts up to $10,000, not to exceed one half of the employee’s amount. If you are deemed ineligible due to a previous medical condition, you still retain the ability to purchase spouse coverage. ADDITIONAL OCCURRENCE BENEFIT If you collect full benefits for a critical illness under the plan and later are diagnosed with one of the remaining covered critical illnesses, then we will pay the full benefit amount for each additional illness. Occurrences must be separated by at least six months or for cancer at least six months treatment free. REOCCURRENCE BENEFIT If you collect full benefits for a covered condition and are later diagnosed with the same condition, we will pay the full benefit again. The two dates of diagnosis must be separated by at least 12 months, or for cancer at least 12 months treatment-free. Cancer that has spread (metastasized), even though there is a new tumor, will not be considered an additional occurrence unless you have gone treatment-free for 12 months. CHILD COVERAGE AT NO ADDITIONAL COST Each dependent child is covered at 25 percent of the primary insured’s benefit amount at no additional charge.
ADDITIONAL BENEFITS RIDER (This benefit is paid based on your selected benefit amount.) PARALYSIS
100%
SEVERE BURNS
100%
COMA
100%
LOSS OF SPEECH / S IGHT / HEARING
100%
HEART EVENT RIDER (This benefit is paid based on your selected benefit amount.) OPEN HEART SURGERIES (Category I: Coronary Artery Bypass Surgery (CABS)*, Mitral Valve Replacement or Repair, Aortic Valve Replacement or Repair, Surgical Treatment of Abdominal Aortic Aneurysm). *Payment of this benefit will still reduce the benefit payable for Heart Attack by 25%.
100%
INVASIVE HEART PROCEDURE (Category II: AngioJet Clot Busting, Balloon Angioplasty, Laser Angioplasty, Atherectomy, Stent Implantation, Cardiac Catheterization, Automatic Implantable (or Internal) Cardioverter Defibrillator, Pacemakers)
10%
*Benefits from the Heart Event Rider and certificate will not exceed 100% of the maximum applicable benefit. When you purchase the Heart Event Rider, the 25% CABS partial benefit in your certificate is increased to 100%. That means the CABS benefit in the Heart Event Rider, combined with the benefit in your certificate, equal 100% of the maximum benefit—not 125%. We will pay the indicated percentages of your maximum benefit if you are treated with one of the specified surgical procedures (Category I) or interventional procedures (Category II) shown; treatment is incurred while coverage is in force; treatment is recommended by a physician; and is not excluded by name or specific description. This benefit is paid based on your selected benefit amount. We will pay the indicated percentages of your maximum benefit if you are treated with one of the specified surgical procedures (Category I) or interventional procedures (Category II) shown; treatment is incurred while coverage is in force; treatment is recommended by a physician; and is not excluded by name or specific description. This benefit is paid based on your selected benefit amount. 43
Critical Illness INDIVIDUAL ELIGIBILITY Issue Ages Employee: 18-69 Spouse: 18-69 Children under age 26 All full-time employees, working at least 20 hours or more weekly are eligible to apply. If an employee is eligible, their spouse is eligible for coverage and all children of the Insured who are less than twenty-six (26) years of age. Seasonal and temporary workers are not eligible to participate.
LIMITATIONS AND EXCLUSIONS If the coverage outlined in this summary will replace any existing coverage, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy. The applicable benefit amount will be paid if: the date of diagnosis occurs while the certificate is in force; and the cause of the illness is not excluded by name or specific description.
EXCLUSIONS Benefits will not be paid for loss due to: Intentionally self-inflicted injury or action; Suicide or attempted suicide while sane or insane; Illegal activities or participation in an illegal occupation; War, whether declared or undeclared or military conflicts, participation in an insurrection or riot, civil commotion or state of belligerence; Substance abuse; or Pre-Existing Conditions (except as stated below). No benefits will be paid for loss which occurred prior to the effective date. No benefits will be paid for diagnosis made or treatment received outside of the United States.
PRE-EXISTING CONDITION LIMITATION Not applicable to cancer and/or carcinoma in situ. Pre-Existing Condition means a sickness or physical condition which, within the 12-month period prior to the effective date, resulted in you receiving medical advice or treatment. We will not pay benefits for any critical illness starting within 12 months of the effective date which is caused by, contributed to, or resulting from a pre-existing condition. A claim for benefits for loss starting after 12 months from the effective date will not be reduced or denied on the grounds that it is caused by a preexisting condition. A critical illness will no longer be considered pre-existing at the end of 12 44
consecutive months starting and ending after the effective date.
CONTINUATION PRIVILEGE When coverage would otherwise terminate because you end employment with the employer, coverage may be continued. You may continue the coverage that is in force on the date employment ends, including dependent coverage then in effect. You must apply to us in writing within 31 days after the date that the insurance would terminate. You may be allowed to continue the coverage until the earlier of the date you fail to pay the required premium or the date the group master policy is terminated. Coverage may not be continued if you fail to pay any required premium or the group master policy terminates.
TERMINATION Coverage will terminate on the earliest of: (1) The date the master policy is terminated; (2) The 31st day after the premium due date if the required premium has not been paid; (3) The date the insured ceases to meet the definition of an employee as defined in the master policy; or (4) The date the employee is no longer a member of the class eligible. Coverage for an insured spouse or dependent child will terminate the earliest of: (1) the date the plan is terminated; (2) the date the spouse or dependent child ceases to be a dependent; (3) the premium due date following the date we receive your written request to terminate coverage for his or her spouse and/or all dependent children.
TERMS YOU NEED TO KNOW The Effective Date of your insurance will be the date shown on the certificate schedule. Employee means the insured as shown on the certificate schedule. Spouse means your legal wife or husband. Dependent Children means your natural children, step-children, foster children, adopted children or children placed for adoption, who are under age 26. Child(ren) also include grandchildren, who are unmarried and under age 26. These dependents must also be: your dependents for federal income tax purposes; and/or dependents for whom you must provide medical support under an order issued under Chapter 154, Family Code (or enforceable by a court order in your state).
Critical Illness Your natural children born after the effective date of the rider will be covered from the moment of birth. A child you adopt may be enrolled the date you become a party to a suit in which you seek to adopt the child or the date the adoption becomes final, at your option. If Employee or Employee/ Spouse coverage is in force and you desire uninterrupted coverage for a newborn or adopted child, you must notify us within 31 days of the child’s birth or the date you become a party to a suit in which you seek to adopt the child or the date the adoption becomes final. Coverage for newborn or adopted children will be in effect through the 31st day following the date of such event. Upon notification, we will advise you of the additional premium due. If your children are covered under the rider, it is not necessary for you to notify us of the birth of a child or the date you become a party to a suit in which you seek to adopt the child or the date the adoption becomes final, and an additional premium payment will not be required. Coverage on dependent children will terminate on the child’s 26th birthday. However, if any child is incapable of selfsustaining employment due to mental or physical handicap and is dependent on his parent(s) for support, the above age 26 shall not apply. Proof of such incapacity and dependency must be furnished to us within 31 days following such 26th birthday.
Non Tobacco Employee Rates (Children covered at 25% of Employee amount at no charge) Age Bracket $10,000 $20,000 18—29 $7.25 $12.75 30—39 $10.65 $19.55 40—49 $20.45 $39.15 50—59 $33.08 $64.42 60—69 $51.75 $101.75
Non Tobacco Spouse Rates (Limited to 50% of employee election) Age Bracket $5,000 $10,000 18—29 $4.50 $7.25 30—39 $6.20 $10.65 40—49 $11.10 $20.45 50—59 $17.42 $33.08 60—69 $26.75 $51.75
Tobacco Employee Rates (Children covered at 25% of Employee amount at no charge) Age Bracket $10,000 $20,000 18—29 $10.45 $19.15 30—39 $16.65 $31.55 40—49 $40.35 $78.95 50—59 $63.55 $125.35 60—69 $100.45 $199.15
Tobacco Spouse Rates (Limited to 50% of employee election) Age Bracket $5,000 $10,000 18—29 $6.10 $10.45 30—39 $9.20 $16.65 40—49 $21.05 $40.35 50—59 $32.65 $63.55 60—69 $51.10 $100.45
45
NBS
FSA (Flexible Spending Account)
YOUR BENEFITS PACKAGE
PLAY VIDEO
About this Benefit 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.
FLIP TOâ&#x20AC;Ś PG. 11 FOR HSA VS. FSA COMPARISON
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 46 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
FSA (Flexible Spending Account) NBS Flexcard
When Will I Receive My Flex Card?
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.
NBS Prepaid MasterCard® Debit Card
Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you need a replacement card please contact NBS directly at (800) 274-0503.
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.
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!
For a list of sample expenses, please refer to the Alamo Heights ISD benefit website: www.mybenefitshub.com/alamoheightsisd
NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: service@nbsbenefits.com
DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses.
FSA Annual Contribution Max: $2,650
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
47
FSA Frequently Asked Questions 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:
Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid
Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers
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.mybenefitshub.com/alamoheightsisd
48
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). Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.
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.mybenefitshub.com/ alamoheightsisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.
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!
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. 2. 3. 4.
Complete and sign a claim form (available on our website) or an online claim. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. Fax or mail signed form and documentation to NBS. 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 or rollover after the Plan year ends for you to submit qualified claims for any unused funds.
49
HSA BANK
HSA (Health Savings Account)
YOUR BENEFITS PACKAGE
PLAY VIDEO
About this Benefit A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.
The interest earned in an HSA is tax free.
Money withdrawn for medical spending never falls under taxable income.
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 50 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.
What is an HSA?
A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.
Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.
Examples of Qualified Medical Expenses
Surgery Braces Contact lenses Dentures Eyeglasses Vaccines
For a list of sample expenses, please refer to the Alamo Heights ISD website at www.mybenefitshub.com/alamoheightsisd
HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com
Using Funds Debit Card You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements. You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.
2018 Annual HSA Contribution Limits Individual: $3,450 Family: $6,900 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000. Health Savings accountholder Age 55 or older (regardless of when in the year an accountholder turns 55) Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated) 51
How the HSA Plan Works A Health Savings Account (HSA) is an individually-owned, tax-advantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through self-directed investment options1.
How an HSA works:
You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well. You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings. Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes). Check balances and account information via HSA Bank’s Internet Banking 24/7.
Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally: You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B. You cannot be covered by TriCare. You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA). You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse). You must be covered by the qualified HDHP on the first day of the month. When you open an account, HSA Bank will request certain information to verify your identity and to process your application.
What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2. 52
2018 Annual HSA Contribution Limits Individual = $3,450 Family = $6,900
Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.
How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how: Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible. HSA funds earn interest and investment earnings are tax free. When used for IRS-qualified medical expenses, distributions are free from tax.
IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.
How the HSA Plan Works Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)
Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRSqualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs
Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays
For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081
1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 53
AUL A ONEAMERICA COMPANY YOUR BENEFITS PACKAGE
Life and AD&D
PLAY VIDEO
About this Benefit 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.
Motor vehicle crashes are the
#1
cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.
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 54 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Life and AD&D AUL's Group Voluntary Term Life and AD&D Insurance Terms and Definitions Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 30 hours per week.
Flexible Choices: Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.
Accidental Death & Dismemberment (AD&D) If approved for this benefit, additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract. AD&D coverage is not included for dependents.
Continuation of Coverage Options: Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70.
OR Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.
Guaranteed Issue Amounts: This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability.
Waiver of Premium: If approved, this benefit waives your and your dependents' insurance premium in case you become totally disabled and are unable to collect a paycheck.
Employee Guaranteed Issue Amount
$150,000
Spouse Guaranteed Issue Amount
$30,000
Child Guaranteed Issue Amount
$10,000
Reductions: Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule.
Timely Enrollment: Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.
Evidence of Insurability: If you elect a benefit amount over the Guaranteed Issue Amount shown above for you or your eligible dependents, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you and / or your dependents will be approved or declined for insurance coverage by AUL.
Age:
70
75
Reduces To:
65%
50%
This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued.
55
Life and AD&D Voluntary Term Life including matching AD&D Coverage Monthly Payroll Deduction Illustration About your benefit options:
You may select a minimum benefit of $10,000 up to a maximum amount of $150,000, in increments of $10,000, not to exceed 5 times your annual base salary only, rounded to the next higher $10,000. Amounts requested above $150,000 for an Employee, $30,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. Employee must select coverage to select any Dependent coverage. AD&D coverage is not included for dependents. Dependent coverage cannot exceed 50% of the Voluntary Term Life amount selected by the Employee. A Spouse must be under age 70 to be eligible for benefits.
EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life & AD&D
0-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$10,000
$2.10
$2.10
$2.10
$2.10
$2.10
$2.10
$2.10
$2.10
$2.10
$2.10
$6.30
$15.30
$15.30
$20,000
$4.20
$4.20
$4.20
$4.20
$4.20
$4.20
$4.20
$4.20
$4.20
$4.20
$12.60
$30.60
$30.60
$30,000
$6.30
$6.30
$6.30
$6.30
$6.30
$6.30
$6.30
$6.30
$6.30
$6.30
$18.90
$45.90
$45.90
$40,000
$8.40
$8.40
$8.40
$8.40
$8.40
$8.40
$8.40
$8.40
$8.40
$8.40
$25.20
$61.20
$61.20
$50,000
$10.50
$10.50
$10.50
$10.50
$10.50
$10.50
$10.50
$10.50
$10.50
$10.50
$31.50
$76.50
$76.50
$60,000
$12.60
$12.60
$12.60
$12.60
$12.60
$12.60
$12.60
$12.60
$12.60
$12.60
$37.80
$91.80
$91.80
$70,000
$14.70
$14.70
$14.70
$14.70
$14.70
$14.70
$14.70
$14.70
$14.70
$14.70
$44.10
$107.10 $107.10
$100,000
$21.00
$21.00
$21.00
$21.00
$21.00
$21.00
$21.00
$21.00
$21.00
$21.00
$63.00
$153.00 $153.00
$125,000
$26.25
$26.25
$26.25
$26.25
$26.25
$26.25
$26.25
$26.25
$26.25
$26.25
$78.75
$191.25 $191.25
$150,000
$31.50
$31.50
$31.50
$31.50
$31.50
$31.50
$31.50
$31.50
$31.50
$31.50
$94.50
$229.50 $229.50
SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01 Life Options
0-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
$5,000
$.90
$.90
$.90
$.90
$.90
$.90
$.90
$.90
$.90
$.90
$.90
$10,000
$1.80
$1.80
$1.80
$1.80
$1.80
$1.80
$1.80
$1.80
$1.80
$1.80
$1.80
$15,000
$2.70
$2.70
$2.70
$2.70
$2.70
$2.70
$2.70
$2.70
$2.70
$2.70
$2.70
$20,000
$3.60
$3.60
$3.60
$3.60
$3.60
$3.60
$3.60
$3.60
$3.60
$3.60
$3.60
$25,000
$4.50
$4.50
$4.50
$4.50
$4.50
$4.50
$4.50
$4.50
$4.50
$4.50
$4.50
$30,000
$5.40
$5.40
$5.40
$5.40
$5.40
$5.40
$5.40
$5.40
$5.40
$5.40
$5.40
56
Life and AD&D CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Child(ren) 6 months to age 26
Child(ren) live birth to 6 months
Monthly Payroll Deduction Life Amount
Option 1
$5,000
$1,000
$1.00
Option 2
$10,000
$1,000
$2.00
About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance CompanyÂŽ (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.
57
MASA YOUR BENEFITS PACKAGE
Medical Transport
About this Benefit 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.
A ground ambulance can cost up to
$2,400
and a helicopter transportation fee can cost
over $30,000
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 58 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
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.
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/family coverage.
Emergent Card Example:
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
59
THE HARTFORD YOUR BENEFITS PACKAGE
Hospital Indemnity
PLAY VIDEO
About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.
The median hospital costs per stay have steadily grown to over $10,000.
$8,800
9,600
10,400
2003
2008
2012
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 60 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Hospital Indemnity Who is eligible? You are eligible for this insurance if you are an active full-time employee who works at least 20 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under the age 26.
Can I keep this insurance if I leave my employer or am no longer a member of this group? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.
Coverage Information You have a choice of three hospital indemnity plans, which allows you the flexibility to enroll for the coverage that best meets your current financial protection needs. Benefit amounts are based on the plan in effect for you or an insured dependent at the time the covered event occurs. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s).
PLAN INFORMATION
Low Plan
Mid Plan
High Plan
Coverage Type
On and off-job (24 hour)
On and off-job (24 hour)
On and off-job (24 hour)
Covered Events
Illness and Injury
Illness and Injury
Illness and Injury
HSA Compatible
Yes
Yes
Yes
BENEFITS HOSPITAL CARE
Low Plan
Mid Plan
High Plan
First day hospital confinement
Up to 1 day per year
$500
$1,000
$2,000
Daily hospital confinement (Day2+)
Up to 90 days per year
$100
$150
$200
Daily ICU confinement
Up to 30 days per year
$200
$300
$400
Low Plan
Mid Plan
High Plan
Ability Assist® EAP1 – 24/7/265 access to help for financial, legal or emotional issues
Included
Included
Included
HealthChampionSM1 – Administrative & clinical support following serious illness or injury
Included
Included
Included
VALUE ADDED SERVICES
Premiums (Per Month) Rates and/or benefits can change. Tier
Low Plan
Mid Plan
High Plan
Employee
$9.02
$15.99
$27.87
EE +Spouse
$17.14
$30.32
$52.75
EE + Children
$16.97
$29.89
$51.67
EE + Family
$26.40
$46.52
$80.50
61
TEXAS LIFE
Individual Life
YOUR BENEFITS PACKAGE
PLAY VIDEO
About this Benefit 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.
Experts recommend at least
x 10 your gross annual income in coverage when purchasing life insurance.
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 62 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Individual Life Life Insurance Highlights Flexible Premium Life Insurance to Age 121. Policy Form PRFNGNI-10 See the PURELIFE-plus brochure for details. Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit.
DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.
The policy, PURELIFE-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features:
High Death Benefit. With one of the highest death benefit available at the worksite1, PURELIFE-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.
Minimal Cash Value. Designed to provide high death benefit, PURELIFE-plus does not compete with the cash accumulation in your employer-sponsored retirement plans.
Long Guarantees2. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up).
Refund of Premium. Unique in the marketplace, PURELIFE-plus offers you a refund of 10 years’ premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)
Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.) ICC ULABR-07 or ULABR07
You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren3. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details.
₁Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2012 ₂Guarantees are subject to product terms, exclusions, limitations and the insurer's claimspaying ability and financial strength. ₃Coverage and spouse/domestic partner eligibility may vary by state. Coverage for children and grandchildren not available in Washington. Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships, and legally recognized familial relationships. Texas Life is licensed to do business in the District of Columbia and every state but New York.
63
DEER OAKS
EAP (Employee Assistance Program)
YOUR BENEFITS PACKAGE
About this Benefit An Employee Assistance Plan (EAP) is an employee benefit program offered to help employees manage personal and professional problems that might adversely impact their work performance, health, and well-being. Employee Assistance Plans generally include short-term counseling and referral services for employees and their household members. Your Employee Assistance Program benefit is provided to you by your employer.
38%
of employees have missed life events because of bad worklife balance.
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 64 Alamo Heights ISD Benefits Website: www.mybenefitshub.com/alamoheightsisd
Employee Assistance Program (EAP) - EMPLOYER PAID The Deer Oaks Employee Assistance Program (EAP) is a free service provided for you and your dependents by your employer. This program offers a wide variety of counseling, referral, and consultation services, which are all designed to assist you and your family in resolving work/life issues in order to live happier, healthier, more balanced lives. These services are completely confidential and can be easily accessed by calling the toll-free Helpline. Below is an overview of the services available through your EAP: Eligibility: All employees and their household members/ dependents are eligible to access the EAP. This includes retirees and employees who have recently separated from their employer. Assessment & Counseling: A network of 54,000+ mental health providers throughout the United States is available to provide in-person assessment and counseling services to members wherever they may reside. Counselors may also conduct comprehensive assessments by phone and provide in-themoment telephonic support and crisis intervention. Tele-Language Services: Deer Oaks has the ability to provide therapy in a language other than English if requested. Services are available for telephonic interpretation in over 190 of the most commonly spoken languages and dialects. Referrals & Community Resources: Counselors provide referrals to community resources, member health plans, support groups, legal resources, and child/elder care services. Advantage Legal Assist: Free 30-minute telephonic consultation with a plan attorney; free 30-minute in-person consultation; 25% discount on hourly attorney fees if representation is required; unlimited online access to a wealth of educational legal resources, links, tools and forms; interactive online Simple Will preparation; access to state agencies to obtain birth certificates and other records. Advantage Financial Assist: Unlimited telephonic consultation with a financial counselor qualified to advise on a range of financial issues such as bankruptcy prevention, debt reduction and financial planning; supporting educational materials available; credit report review by a financial counselor and tips for improvement; objective, pressure-free advice; unlimited online access to a wealth of educational financial resources, links, tools and forms (i.e. tax guides, financial calculators, etc.). Interactive Online Simple Will Preparation: Create a legallybinding simple state specific will at no cost through a step by step online "interview process." Access this service through www.deeroaks.com
Credit Monitoring: Free credit reports and credit monitoring available via the legal/financial center ID Recovery: Free 30-minute telephonic consultation with an Identity Recovery Professional; customized action plan and consultation; ongoing ID recovery guidance available as needed; free ID monitoring service. Monthly Electronic Newsletters: Employees and supervisors receive monthly e-newsletters covering a variety of topics including health and wellness, work/life balance issues, conflict resolution, leadership, and more. Online Tools & Resources: Log on to www.deeroaks.com to access an extensive topical library containing health and wellness articles, child and elder care resources, work/life balance resources and webinars. Contact (866)327-2400 / eap@deeroaks.com Work/Life Services: Work/Life Consultants are available to assist members with a wide range of daily living resources such as pet sitters, event planners, home repair, tutors and moving services. Simply call the Helpline for resource and referral information. Find-Now Child & Elder Care Program: This program assists participants caring for children and/or aging parents with the search for licensed, regulated, and inspected child and elder care facilities in their area. Work/Life Consultants assess each member's needs, provide guidance, resources, and a list of up to three (3) referrals within 12 hours of the call. Searchable databases and other resources are also available on the Deer Oaks website. Health & Wellbeing: Deer Oaks encourages not only the mental health, but also the physical health and wellbeing of our members. Work/Life Consultants are available to provide referrals to providers, specialists, and resources to meet specific needs such as safety programs, support groups, fitness centers and nutrition programs. Critical Incident Stress Management: Traumatic events can be extremely disruptive to the well-being and productivity of employees. Deer Oaks will respond quickly when asked to provide Critical Incident Stress Management Services for any major company incident. Take the High Road: Deer Oaks reimburses members for their cab fares in the event that they are incapacitated due to impairment by a substance or extreme emotional condition. This service is available once per year per participant with a maximum reimbursement of $45.00 (excludes tips).
65
NOTES
66
NOTES
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WWW.MYBENEFITSHUB.COM/ ALAMOHEIGHTSISD 68