BURKBURNETT ISD
BENEFIT GUIDE EFFECTIVE: 01/01/2018 - 12/31/2018 WWW.MYBENEFITSHUB.COM/ BURKBURNETTISD
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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. HSA vs. FSA Comparison TRS-ActiveCare APL MEDlink® NBS Health Savings Account (HSA) MDLIVE Telehealth Cigna Dental Superior Vision Unum Disability Loyal American Cancer APL Accident The Hartford Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider Voya Critical Illness NBS Flexible Spending Account (FSA) MASA Medical Transport 2
3 4-5 6-11 6 7 8 9 10 11 12-13 14-17 18-19 20-21 22-25 26-27 28-31 32-35 36-39 40-45 46-49 50-53 54-57 58-59
FLIP TO... PG. 4 HOW TO HOW TO ENROLL ENROLL
PG. 6 SUMMARY PAGES
PG. 12 YOUR BENEFITS
Benefit Contact Information BURKBURNETT ISD BENEFITS
DENTAL
LIFE AND AD&D
Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/burkburnettisd
Cigna (800) 244-6224 www.cigna.com
The Hartford (800) 583-6908 www.thehartford.com Will Prep/Estate Guidance: Code WILLHLF www.estateguidance.com/wills Travel Assistance/ID Theft: (800) 243-6108
BURKBURNETT ISD BENEFITS OFFICE
VISION
CRITICAL ILLNESS
(940) 569-3326 ext. 2010 www.burkburnettisd.org
Superior Vision Network: Superior Select Southwest (800) 507-3800 www.superiorvision.com
Voya (800) 955-7736 www.voya.com
TRS ACTIVECARE MEDICAL
DISABILITY
FAMILY PROTECTION PLAN
Aetna (800) 222-9205 www.trsactivecareaetna.com
Unum (800) 583-6908 Claim Status: (800) 858-6843 EAP: (800) 854-1446 Travel Assistance: (800) 872-1414 www.unum.com
5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com
MEDLINK®
CANCER
MEDICAL TRANSPORT
American Public Life (800) 256-8606 www.ampublic.com
Loyal American (800) 366-8354
MASA U.S. (800) 423-3226 International (800) 643-9023 www.masamts.com
HEALTH SAVINGS ACCOUNT
ACCIDENT
COBRA
National Benefit Services (800) 274-0503 www.nbsbenefits.com
American Public Life (800) 256-8606 www.ampublic.com
Dental, Vision, MEDlink®, Med Flex National Benefit Services (800) 274-0503 www.nbsbenefits.com
TELEHEALTH
FLEXIBLE SPENDING ACCOUNT
MDLIVE (888) 365-1663 www.consultmdlive.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS BBISD ” 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 BBISD ” to 313131 OR SCAN
How to Log In
1 BENEFIT INFO
INTERACTIVE TOOLS
2 3
www.mybenefitshub.com/ burkburnettisd
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.
ONLIINE 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: MASA provides medical emergency transportation and
covers transport cost when your insurance falls short. MASA does not use a network so you and your family are covered nationwide for $9 per month. Zebit offers free financial education and interest free
financing for a closed marketplace of competitively priced products. Members pay back loan over 6 months. First payment due at purchase. Not enrolled in the hub, eligible employees can register for free at www.zebit.com/hi/burkburnett (you must be employed by BISD over 1 year & earn $10K+ for the interest free credit). MEDlink® with APL: MEDlink® provides supplemental
coverage to help offset deductibles and coinsurance of hospitalization. You must be enrolled in BISD’s medical insurance to be eligible for MEDlink®. If enrolled in a MEDlink® plan you are not eligible for an HSA.
FSA with National Benefit Services: Eligible Flex
expenses must be incurred within the plan year, contributions are use-it or lose-it. You MUST re-elect a new contribution amount every year to continue to participate. Current Healthcare FSA participants, KEEP your FSA debit card, new funds will be available mid January. New participants receive flex cards in late January. Health Savings Accounts with NBS: HSA accounts are
available to employees enrolled in a high-deductible health plan. Funds roll over and accumulate year to year and accounts are not prefunded. There is a monthly $2 service fee. You are not eligible for an HSA if you have MEDlink® or have access to FSA funds. Term Life Insurance by The Hartford: Group Term Life
and AD&D are inexpensive ways to purchase life insurance. Coverage is typically available to You, Your Spouse and Dependent Children. New and Existing participants who increase life coverage will be contacted by The Hartford in December with a link for a required online health statement.
Login and complete your benefit enrollment from 10/30/2017 - 11/30/2017 (5PM) Enrollers will be on site from11/07/2017 - 11/09/2017 Enrollment assistance is available by calling Financial Benefit Services at (800) 583-6908 to speak to a representative Monday—Friday between 8am – 5pm CST Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers
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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 31 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.
burkburnettisd
Changes, additions or drops may be made only during the
Click on the benefit plan you need information on (i.e.,
annual enrollment period without a qualifying event.
Dental) and you can find the forms you need under the Benefits and Forms section.
Employees must review their personal information and verify that dependents they wish to provide coverage for are
How can I find a Network Provider?
included in the dependent profile. Additionally, you must
For benefit summaries and claim forms, go to your school
notify your employer of any discrepancy in personal and/or benefit information.
Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
district’s benefit website: www.mybenefitshub.com/ burkburnettisd Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to
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.
receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.
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 800-583-6908 for assistance.
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If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
SUMMARY PAGES
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 the Burkburnett 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 January 1, 2018, you must be actively-at-work on January 1, 2018 to be eligible for your new benefits. PLAN
CARRIER
MAXIMUM AGE
CONTINUATION
Medical
Aetna
To 26
COBRA (Wellsystems)
MEDlink®
APL
To 26
COBRA (NBS)
Health Savings Account
NBS
Tax Dependent
Contact NBS
Telehealth
MDLIVE
Unmarried to 26
Individual Plan
Dental
Cigna
To 26
COBRA (NBS)
Vision
Superior Vision
To 26
COBRA (NBS)
Cancer
Loyal American
Unmarried to 25
Portable*
Accident
APL
To 26
Portable*
Voluntary Term Life
The Hartford
Unmarried to 26
Port/Convert*
Individual Life
5Star FPP
Medical Flex
NBS
To 26
COBRA (NBS)
Critical Illness
Voya
Unmarried to 26
Portable*
Portable*
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. *Contact carrier within 30 days of termination to be eligible for continuation.
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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 01/01/2018 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 Supplemental Plans: January 1st through December 31st Medical Plans: 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
Calendar Year
orders to take drugs, or received medical care or services
January 1st through December 31st
(including diagnostic and/or consultation services).
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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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
$1,350 single (2018) $2,700 family (2018) $3,450 single (2018) $6,900 family (2018)
N/A $2,600
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
Funding
You will only have access to HSA funds that have been contributed up to that point. HSAs are not front loaded.
You will have access to the entire annual contribution amount on the effective date of your FSA. FSA balance is front loaded to provide access to the entire annual contribution.
FLIP TO FOR HSA INFORMATION
PG. 18
FLIP TO FOR FSA INFORMATION
PG. 54 11
2017 – 2018 TRS-ActiveCare Plan Highlights Effective September 1, 2017 through August 31, 2018 | In-Network Level of Benefits*
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 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 Smokingcessationcounseling– 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/obesitycounseling– unlimited to
• Well woman exam & pap smear – annually age 18 and over • Prostatecancer screening–1 per year age 50 and over • Breastfeeding support – 6 lactation counseling visits
Drug Deductible Short-Term Supply at a Retail Location
Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to
90-day supply)****
Specialty Medications Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply)
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.
Premium Information for ALEX You will need to enter the applicable amount – YOUR ANNUAL COST – from the table below into ALEX when prompted. To determine this cost, ask your Benefits Administrator for your monthly cost (this is the amount you will owe each month after your employer contributes to your coverage). Then multiply your monthly cost by 12 to get YOUR ANNUAL COST (use this amount for ALEX) Individual
$351
$514
$714
+Spouse
$991
$1,264
$1,694
+Children
$671
$834
$1,062
+Family
$1,316
$1,589
$2,004
A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,500 - individual, $5,000 - family) and they pay nothing out of pocket for these drugs. The list of drugs is on the TRS-ActiveCare website. ***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. 13 ****Participants can fill 32-day to 90-day supply through mail order.
APL YOUR BENEFITS PACKAGE
MEDlinkÂŽ IV
PLAY VIDEO
About this Benefit Medical supplement is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset outof-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 14 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
MEDlink® Limited Benefit Medical Expense Supplemental Insurance Burkburnett ISD
AMERICAN PUBLIC LIFE YOUR BENEFITS
MEDlink®
THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. SUMMARY OF BENEFITS Base Policy
Option 1
Option 2
In-Hospital Benefit - Maximum In-Hospital Benefit
$1,500 per confinement
$2,500 per confinement
Outpatient Benefit
up to $200 per treatment
up to $200 per treatment
$25 per treatment; $125 max per family per Calendar Year
$25 per treatment; $125 max per family per Calendar Year
Physician Outpatient Treatment Benefit
Option 1 Total Monthly Premiums by Plan* Issue Ages
Issue Ages
Issue Ages
Employee Only
$21.50
$32.00
$49.00
Employee + Spouse
$39.50
$59.00
$88.00
Employee + Child(ren)
$36.50
$47.00
$64.00
Family Coverage
$54.50
$74.00
$103.00
Issue Ages
Issue Ages
Issue Ages
Employee Only
$28.00
$44.50
$68.50
Employee + Spouse
$51.50
$81.50
$122.50
Option 2 Total Monthly Premiums by Plan*
Employee + Child(ren)
$45.50
$62.00
$86.00
Family Coverage
$69.00
$99.00
$140.00
Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.
About this Benefit MEDlink® is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co -payments and coinsurance of your medical plan.
DID YOU KNOW?
33% of total healthcare costs are paid out-of-pocket.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the West Texas EBC Benefits Website: www.mybenefitshub.com/wtxebc
Eligibility
In-Hospital Benefit
This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later.
Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.
Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above.
Outpatient Benefits
A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.
Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.
Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.
Physician Outpatient Treatment Benefit
15
APSB-22330(TX)-0116 MGM/FBS Burkburnett ISD
MEDlink® Limited Benefit Medical Expense Supplemental Insurance Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased. This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.
Exclusions We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.) (l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.) (p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.)
(q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (1) resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or (2) due to congenital disease or anomaly of a covered newborn child. (s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborn care; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.
Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy. Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage. We may end the coverage of any Covered Person who submits a fraudulent claim. We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.
2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606
This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | West Texas EBC 16
APSB-22330(TX)-0116 MGM/FBS Burkburnett ISD
MEDlinkÂŽ Limited Benefit Medical Expense Supplemental Insurance
17
NBS
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 18 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
HSA (Health Savings Account) 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. Potential to build more savings through investing. If you maintain a minimum balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.
Using Funds Pre-paid Debit Card: You may use the card to pay merchants or service providers that accept Master Card credit cards, so there is no need to pay cash up front and wait for reimbursements.
2018 Annual HSA Contribution Limits Individual: $3,450 Family: $6,900 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch‐up” contribution to their HSA.
Participant Account Web Access www.nbsbenefits.com A Health Savings Account (HSA) works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck ‐ before taxes– into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses.
A Health Savings Account (HSA):
Grows with you. If you maintain a balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. An additional investment fee of $2.50/month is charged on balances less than $3,000. Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for non-eligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.
For a list of sample expenses, please refer to the Burkburnett ISD benefit website at www.mybenefitshub.com/ burkburnettisd
NBS Contact Information P.O. Box 6980 West Jordan, UT 84084 Phone‐800‐274‐0503 Fax‐800‐478‐1528 Email: service@nbsbenefits.com
Will my HSA Funds be up fronted to me? Like a savings account, you can only withdrawal what you’ve contributed to the account. Funds are not up fronted. Are there any monthly fees? There is an Administrative Fee of $2.00/month on all balances. There is an additional Investment Fee of $2.50/month for accounts invested in mutual funds if balance is under $3,000.
19
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 20 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
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? $8.00 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 21 abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113
CIGNA
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 22 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Dental PPO - Low Plan Benefits
Total Cigna Dental Choice In-Network Out-of-Network Total Cigna Choice
Network Calendar Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**
$1,000
$1,000
$50 per person $150 per family
$50 per person $150 per family
Based on Contracted Fees
Maximum Reimbursable Charges
Plan Pays
You Pay
Plan Pays
You Pay**
Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Fluoride Application Sealants
100%
No Charge
100%
No Charge**
Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Space Maintainers (Limited to nonOrthodontic treatment) Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - minor and major
80%*
20%*
80%*
20%*
Class III - Major Restorative Care Crowns Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant
50%*
50%*
50%*
50%*
Not covered
100% of your dentist’s usual fees
Not covered
100% of your dentist’s usual fees
50%*
50%* Subject to plan deductible Subject to plan annual maximum
50%*
Class IV - Orthodontia
50%* Subject to plan deductible Subject to plan annual maximum
Class IX - Implants Deductible Annual Maximum
Semi-Monthly PPO Premiums Tier
Rate
EE Only
$17.34
EE + Spouse
$34.01
EE + Child(ren)
$43.33
Family
$68.22
Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 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 nonprescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. 23
Dental PPO - High Plan Benefits
Total Cigna Dental Choice
Network
In-Network Total Cigna Choice
Out-of-Network
$1,000
$1,000
$50 per person $150 per family
$50 per person $150 per family
Based on Contracted Fees
90th percentile of Reasonable and Customary Allowances
Calendar Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels** Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Fluoride Application Sealants Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Periodontal Scaling and Root Planing Space Maintainers(Limited to nonOrthodontic treatment) Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - All except simple extractions Oral Surgery - Simple Extractions Class III - Major Restorative Care Crowns Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia Lifetime Maximum
Class IX - Implants Deductible Annual Maximum
Semi-Monthly PPO Premiums Tier
Rate
EE Only
$18.42
EE + Spouse
$36.14
EE + Child(ren)
$46.05
Family 24
$72.31
Plan Pays
You Pay
Plan Pays
You Pay**
100%
No Charge
100%
No Charge**
80%*
20%*
80%*
20%*
50%*
50%*
50%*
50%*
50%* $1,000 Dependent children to age 19 50%* Subject to plan deductible Subject to plan annual maximum
50%*
50%*
50%* $1,000 Dependent children to age 19 50%* Subject to plan deductible Subject to plan annual maximum
50%*
50%*
Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 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)Ž 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 nonprescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.
Dental PPO - Low and High Plan Procedure
Exclusions and Limitations
Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Sealants Space Maintainers Prosthesis Over Implant
50% coverage on Class III and IV for 24 months Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Various limits per Calendar year depending on specific test Bitewings: 2 per Calendar 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 Various limitations depending on the service Replacement every 5 years 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 Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years 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 When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses
Alternate Benefit
Benefit Exclusions
Charges in excess of the reasonable and customary allowances Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.
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: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: 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. BSD46380 © 2015 Cigna
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 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Vision Superior Select Southwest Network Benefits
In-Network
Out-of-Network
Covered in full
Up to $35 retail
$150 retail allowance $175 retail allowance
Up to $70 retail Up to $80 retail
Covered in full
Up to $150 retail
Exam Frames Contact Lenses1 Medically Necessary Contact Lenses Lasik Vision Correction
$200 allowance2
Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Lenticular
Semi-Monthly Premiums EE Only EE + 1 Dependent EE + Family
$4.31 $7.34 $10.74
Co-Pays Exam Materials
$10 $25
Services/Frequency Covered in full Covered in full Covered in full See description3 Covered in full
Up to $25 retail Up to $40 retail Up to $45 retail Up to $45 retail Up to $80 retail
Co-pays apply to in-network benefits; co-pays for out-ofnetwork 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.
Exam Frame Lenses Contact Lenses
12 months 12 months 12 months 12 months
(Based on date of service) 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
Glasses available online at www.ditto.com Contacts available online at www.ContactsDirect.com/ superiorvision
27
UNUM 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 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Disability Policy # 217339
Pre-Existing Condition Exclusion
Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.
Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date of coverage.
Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.
Guarantee Issue Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period. Newly Hires: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period. Benefits are subject to the pre-existing condition exclusion referenced later in this document.
Benefit Duration Your duration of benefits is based on your age when the disability occurs. Plan: ADEA II: Your duration of benefits is based on the following table: Age at Disability Less than age 60 Age 60 through 64 Age 65 through 69 Age 70 and over
Maximum Duration of Benefits To age 65, but not less than 5 years 5 years To age 70, but not less than 1 year 1 year
Delayed Effective Date of Coverage If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.
Please see your Plan Administrator for your eligibility date.
Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $8,000. Please see your Plan Administrator for the definition of monthly earnings. The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).
Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits.
Waiver of Premium After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving benefits.
Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com Š2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
You may choose an Elimination Period (injury/sickness) of 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.) 29
Disability BURKBURNETT INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A
Product: Educator Select Income Protection Plan
ADEAII Duration of Benefits Elimination Period (Days)
Injury (Days) Sickness (Days) Annual Earnings 3600 5400 7200 9000 10800 12600 14400 16200 18000 19800 21600 23400 25200 27000 28800 30600 32400 34200 36000 37800 39600 41400 43200 45000 46800 48600 50400 52200 54000 55800 57600 59400 61200 63000 64800 66600 68400 70200 72000 73800 75600 7740030
Monthly Earnings 300 450 600 750 900 1050 1200 1350 1500 1650 1800 1950 2100 2250 2400 2550 2700 2850 3000 3150 3300 3450 3600 3750 3900 4050 4200 4350 4500 4650 4800 4950 5100 5250 5400 5550 5700 5850 6000 6150 6300 6450
Maximum Monthly Benefit 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 4100 4200 4300
14* 14*
30* 30*
60 60
90 90
180 180
5.68 8.52 11.36 14.20 17.04 19.88 22.72 25.56 28.40 31.24 34.08 36.92 39.76 42.60 45.44 48.28 51.12 53.96 56.80 59.64 62.48 65.32 68.16 71.00 73.84 76.68 79.52 82.36 85.20 88.04 90.88 93.72 96.56 99.40 102.24 105.08 107.92 110.76 113.60 116.44 119.28 122.12
4.88 7.32 9.76 12.20 14.64 17.08 19.52 21.96 24.40 26.84 29.28 31.72 34.16 36.60 39.04 41.48 43.92 46.36 48.80 51.24 53.68 56.12 58.56 61.00 63.44 65.88 68.32 70.76 73.20 75.64 78.08 80.52 82.96 85.40 87.84 90.28 92.72 95.16 97.60 100.04 102.48 104.92
3.92 5.88 7.84 9.80 11.76 13.72 15.68 17.64 19.60 21.56 23.52 25.48 27.44 29.40 31.36 33.32 35.28 37.24 39.20 41.16 43.12 45.08 47.04 49.00 50.96 52.92 54.88 56.84 58.80 60.76 62.72 64.68 66.64 68.60 70.56 72.52 74.48 76.44 78.40 80.36 82.32 84.28
2.22 3.33 4.44 5.55 6.66 7.77 8.88 9.99 11.10 12.21 13.32 14.43 15.54 16.65 17.76 18.87 19.98 21.09 22.20 23.31 24.42 25.53 26.64 27.75 28.86 29.97 31.08 32.19 33.30 34.41 35.52 36.63 37.74 38.85 39.96 41.07 42.18 43.29 44.40 45.51 46.62 47.73
1.56 2.34 3.12 3.90 4.68 5.46 6.24 7.02 7.80 8.58 9.36 10.14 10.92 11.70 12.48 13.26 14.04 14.82 15.60 16.38 17.16 17.94 18.72 19.50 20.28 21.06 21.84 22.62 23.40 24.18 24.96 25.74 26.52 27.30 28.08 28.86 29.64 30.42 31.20 31.98 32.76 33.54
Disability BURKBURNETT INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A Product: Educator Select Income Protection Plan
ADEAII Duration of Benefits Elimination Period (Days)
Injury (Days) Sickness (Days) Annual Earnings
Monthly Earnings
79200 81000 82800 84600 86400 88200 90000 91800 93600
6600 6750 6900 7050 7200 7350 7500 7650 7800
Maximum Monthly Benefit 4400 4500 4600 4700 4800 4900 5000 5100 5200
14* 14*
30* 30*
60 60
90 90
180 180
124.96 127.80 130.64 133.48 136.32 139.16 142.00 144.84 147.68
107.36 109.80 112.24 114.68 117.12 119.56 122.00 124.44 126.88
86.24 88.20 90.16 92.12 94.08 96.04 98.00 99.96 101.92
48.84 49.95 51.06 52.17 53.28 54.39 55.50 56.61 57.72
34.32 35.10 35.88 36.66 37.44 38.22 39.00 39.78 40.56
31
LOYAL AMERICAN
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 32 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Cancer Additional Benefit Amounts
Plan A Plan B Plan C Maximum Maximum Maximum
$50 Per $100 Per $100 Per Calendar Calendar Calendar Year Year Year Basic Benefit– We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x‐ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer) CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer) CA15‐3 (blood test for breast cancer) serum protein electrophesis (blood test for myeloma) $100 Per $200 Per $200 Per Additional Benefit Calendar Calendar Calendar Year Year Year We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for any dollar payable under the Positive Diagnosis Benefit contained in the base Certificate First Occurrence Benefit Rider (Form LG‐6043) If the Insured Person received a positive diagnosis of internal Cancer, We will pay the $2,000 Once $5,000 Once $5,000 Once First Occurrence benefit amount shown on the Certificate Schedule Per Lifetime Per Lifetime Per Lifetime If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one‐half times the First Occurrence benefit $3,000 Once $7,500 Once $7,500 Once amount shown on the Certificate Schedule Per Lifetime Per Lifetime Per Lifetime $10,000 Per $15,000 Per $20,000 Per Annual Radiation, Chemotherapy, Immunotherapy, and Experimental Treatment Calendar Calendar Calendar Benefit Rider (Form LG‐6045) Year Year Year We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year. Surgical Benefit Rider (Form LG 6048) Surgical Expense ‐ We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the $1,000 $2,500 $2,500 Surgical Schedule shown in this rider. However, in no event will the amount payable Procedure Procedure Procedure exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor Maximum Maximum Maximum will it exceed the expense incurred Anesthesia Expense ‐ We will pay the anesthesia expense incurred, not to exceed $250 $625 $625 25% of the covered Surgical Expense benefit for the operation performed. This Procedure Procedure Procedure includes the services of an anesthesiologist or of an anesthetist under supervision of a Maximum Maximum Maximum physician for the purpose of administering anesthesia Breast Reconstruction ‐ with transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis $900 $2,250 $2,250 (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If Procedure Procedure Procedure this procedure is performed on an Insured Person as the result of a mastectomy for Maximum Maximum Maximum which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit Issued Skin Cancer Surgery Expense ‐ We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) Per Per Per when a surgical operation is preformed on an Insured Person for treatment of a Procedure Procedure Procedure diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer. Annual Cancer Screening Benefit Rider (Form LG‐6041)
33
Cancer Additional Benefit Amounts Continued Daily Hospital Confinement Benefit Rider (form LG‐6042) Confinements of 30 Days or Less ‐ We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer. Confinement of 31 Days or More ‐ If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital. Benefits for an Insured Dependent under Age 21 - The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown in the Certificate Schedule if the Insured Person so confined is a dependent Child under the age of 21.
Plan A Plan B Plan C Maximum Maximum Maximum $150 Per Day
$250 Per Day
$250 Per Day
$300 Per Day
$500 Per Day
$500 Per Day
$300/$600 Per Day
$250/$500 Per Day
$250/$500 Per Day
Additional Benefit Amounts Continued SPECIFIED DISEASE BENEFIT RIDER (FORM LG 60‐52) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. COVERS THESE 38 SPECIFIED DISEASES Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia Botulism Meningitis Tay‐Sachs Disease Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus Budd‐Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis Cystic Fibrosis Myasthenia Gravis Tuberculosis Diptheria Neimann‐Pick Disease Tularemia Encephalitis Osteomyelitis Typhoid Fever Epilepsy Poliomyelitis Undulant Fever Hansen’s Disease Q Fever West Nile Virus Histoplasmosis Rabies Whipple’s Disease Legionnaire’s Disease Reye’s Syndrome Whooping Cough Lyme Disease Rheumatic Fever BENEFITS If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2, or 3, units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continual confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more. This page is an Insert to be used ONLY with Brochure Form LG-6040. If you do not have this Brochure, ask that your agent provide one for you. All exclusions, limitations, definitions and terms of renewability of the Group Limited Benefit Cancer Certificate (form LG-6040) apply to these riders. THESE ARE LIMITED RIDERS. 34
Cancer Optional Benefits You May Select for Additional Premium Hospital Intensive Care Unit Benefit Rider (Form LG‐6047)* Intensive Care Unit Benefit - We will pay the daily Hospital ICU Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or Injury.
$500 Per Day
Double Intensive Care Unit Benefit - We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.
$1,000 Per Day
Step Down Unit Benefit - We will pay one‐half the daily Hospital ICU Benefit amount shown on the Certificate $250 Schedule for an Insured Person’s confinement in a Step Down Unit for sickness or injury. Per Day *Additional Limitations and Exclusions for the Hospital ICU Care Unit Benefit Rider - If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL ICU BENEFIT RIDER REDUCE BY ONE‐HALF AT AGE 75 Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self‐inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner.
MONTHLY RATES
EMPLOYEE
SINGLE PARENT
BASE PLAN A
$19.88
$24.48
EMPLOYEE AND SPOUSE $33.56
BASE PLAN B
$31.62
$37.94
$52.52
$52.52
BASE PLAN C
$35.46
$42.40
$58.82
$58.82
MONTHLY RATES
EMPLOYEE
SINGLE PARENT
BASE PLAN A WITH ICU
$22.20
$27.68
EMPLOYEE AND SPOUSE $37.96
BASE PLAN B WITH ICU
$33.96
$41.12
$56.92
$56.92
BASE PLAN C WITH ICU
$37.78
$45.60
$63.22
$63.22
PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing Conditions during the 12 months after coverage becomes effective for such Insured Person. “Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the effective date of coverage for each Insured Person.
FAMILY $33.56
FAMILY $37.96
EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s coverage regardless of the Date of Positive Diagnosis.
35
AMERICAN PUBLIC LIFE 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 36 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Accident AMERICAN PUBLIC LIFE YOUR BENEFITS
Accident
THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Summary of Benefits* Benefit Description Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit
Level 1 - 1 Unit
Level 2 - 2 Units
Level 3 - 3 Units
Level 4 - 4 Units
$5,000
$10,000
$15,000
$20,000
actual charges up to actual charges up to actual charges up to actual charges up to $500 $1,000 $1,500 $2,000
Daily Hospital Confinement Benefit
$75 per day
Air and Ground Ambulance Benefit
$150 per day
$225 per day
$300 per day
actual charges up to actual charges up to actual charges up to actual charges up to $1,250 $2,500 $3,750 $5,000
Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs
$500 $500 $2,500 $5,000
$1,000 $1,000 $5,000 $10,000
$1,500 $1,500 $7,500 $15,000
$2,000 $2,000 $10,000 $20,000
Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes
$2,500 $5,000
$5,000 $10,000
$7,500 $15,000
$10,000 $20,000
$200 upon admission
$200 upon admission
$200 upon admission
$200 upon admission
Benefit Rider Hospital Admission Benefit
About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.
DID YOU KNOW?
2/3
of disabling injuries suffered by American workers are not work related.
American workers 36% ofreport they always or
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
Level 1 - 1 Unit
$11.70
$20.70
$22.70
$31.70
Level 2 - 2 Units
$18.00
$31.10
$36.40
$49.50
Level 3 - 3 Units
$22.40
$40.20
$46.70
$64.50
Level 4 - 4 Units
$25.40
$46.20
$53.50
$74.30
*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.
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 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
37
APSB-22329(TX)-MGM/FBS Burkburnett ISD
Accident - Continued...
Accident - Continued... Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.
Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.
Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.
Hospital Admission Benefit The maximum benefit is 4 units.
Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3) (4) (5) (6)
(7) (8)
(9) (10)
(11)
Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.
Daily Hospital Confinement Benefit
(12) (13)
The maximum benefit period for this benefit is 30 days per covered accident.
(14)
Accidental Death
(15)
Accidental Death must result within 90 days of the covered accident causing the injury.
Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.
(16)
sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;
If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.
Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.
Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | Burkburnett ISD
38
APSB-22329(TX)-MGM/FBS Burkburnett ISD
APSB-22329(TX)-MGM/FBS Burkburnett ISD
Accident - Continued...
Accident - Continued... Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.
Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.
Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.
Hospital Admission Benefit The maximum benefit is 4 units.
Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3) (4) (5) (6)
(7) (8)
(9) (10)
(11)
Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.
Daily Hospital Confinement Benefit
(12) (13)
The maximum benefit period for this benefit is 30 days per covered accident.
(14)
Accidental Death
(15)
Accidental Death must result within 90 days of the covered accident causing the injury.
Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.
(16)
sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;
If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.
Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.
Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | Burkburnett ISD
39
APSB-22329(TX)-MGM/FBS Burkburnett ISD
APSB-22329(TX)-MGM/FBS Burkburnett ISD
THE HARTFORD 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 40 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Voluntary Life Benefit Highlights What is Voluntary Life Insurance?
Voluntary Life Insurance is coverage that you pay for. Voluntary Life Insurance pays your beneficiary (please see below) a benefit if you die while you are covered. This highlight sheet is an overview of your Voluntary Life Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.
Am I eligible?
You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.
When can I enroll?
You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.
When is it effective?
Coverage goes into effect subject to the terms and conditions of the policy. You must be Actively at Work with your employer on the day your coverage takes effect.
How much Voluntary Life Insurance can I purchase?
You can purchase Voluntary Life Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than the lesser of 5 times your annual Salary or $500,000. Annual Salary is as defined in The Hartford’s contract with your employer.
I already have Voluntary Life Insurance coverage; do I have to do anything?
If you take no action, your coverage and coverage for your eligible dependents will automatically continue with The Hartford subject to the terms of the contract.
Am I guaranteed coverage?
If you enroll during your annual enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $150,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you enroll after your annual or initial enrollment period, evidence of insurability will be required for all coverage amounts.
What is a beneficiary?
Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.
Are there other limitations to enrollment?
If you do not enroll within 31 days of your first day of eligibility, you will be considered a “late entrant.” Typically, late entrants must show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required. This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the Insurance coverage that you have elected may not be in effect. If you elect Voluntary Life Insurance for yourself, you may choose to purchase Spouse Voluntary Life Insurance in increments of $5,000, to a maximum of $125,000. Coverage cannot exceed 50% of the amount of your Employee voluntary/supplemental life insurance coverage. You may not elect coverage for your spouse if they are in active full-time military service or is already covered as an employee under this policy.
Spouse Voluntary Life Insurance
If your spouse is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days. If you enroll during your annual enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $50,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you enroll after your annual or initial enrollment period, evidence of insurability will be required for all coverage amounts. 41
Voluntary Life Benefit Highlights
Child(ren) Voluntary Life Insurance
If you elect Voluntary Life Insurance for yourself, you may choose to purchase Child(ren) Voluntary Life Insurance coverage in increments of $10,000 for each child – no medical information is required. If your dependent child(ren) is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days. Your child(ren) must be at least 15 days but not yet age 26 to be covered. Child(ren) age 26 or older may be covered if they were disabled prior to attaining age 26.
Does my coverage reduce as I get older?
By 35% at age 65 and by 50% at age 70. All coverage cancels at retirement.
Can I keep my Life Coverage if I leave my employer?
Yes, subject to the contract, you have the option of: Converting your group life coverage to your own individual policy (policies). If you leave your employer, Portability is an option that allows you to continue your life insurance coverage. To be eligible, you must terminate your employment prior to Social Security Normal Retirement Age. This option allows you to continue all or a portion of your Life Insurance coverage under a separate Portability term policy. Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does include coverage for your Spouse and Child(ren). To elect Portability, you must apply and pay the premium within 31 days of the termination of your Life Insurance. Evidence of Insurability will not be required. Dependent Spouse Portability is subject to a maximum of $50,000. Dependent Child Portability is subject to a maximum of $10,000.
What is the Living Benefits Option?
If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your Life Insurance. The remaining amount of your Life Insurance would be paid to your beneficiary when you die.
Do I still pay my Life Insurance premiums if I become disabled?
If you become totally disabled before age 60 and your disability lasts for at least 9 months, your Life Insurance premium may be waived. The premium for your dependent’s coverage will also be waived if you are disabled and approved for waiver of premium. Coverage for your dependents will end if the policy terminates.
Important Details
As is standard with most term life Insurance, this Insurance coverage includes limitations and exclusions: The amount of your coverage may be reduced when you reach certain ages. Death by suicide (two years). Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of Insurance will be available to explain your coverage in detail.
This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.
42
Voluntary AD&D Benefit Highlights
What is Voluntary Accidental Death and Dismemberment Insurance?
What does Voluntary AD&D Insurance cover?
Voluntary Accidental Death and Dismemberment Insurance pays your beneficiary (please see below) a death benefit if you die due to a covered accident while you are insured. It also pays you a benefit for certain accidental losses. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail. Death benefits are paid in addition to any life insurance benefits. Voluntary Accidental Death and Dismemberment insurance pays benefits for accidental loss of limbs, thumb and index finger, speech, hearing, and sight. Voluntary Accidental Death and Dismemberment Insurance covers losses that occur away from work or at work. Benefits are paid regardless of any worker’s compensation benefits you collect. This highlight sheet is an overview of your Voluntary Accidental Death and Dismemberment Insurance. You may receive benefits due to certain losses or death from an accident. The covered losses or death can occur up to 365 days after that accident. The policy pays for: 100% of the amount of coverage you purchase in the event of accidental loss of life, or speech and hearing in both ears. One-half (50%) for accidental loss of one hand or foot, sight of one eye, or speech or hearing in both ears. One-quarter (25%) for accidental loss of thumb and index finger of the same hand. Additionally, your employer may have elected optional/supplemental benefits as part of your AD&D coverage. Refer to the certificate of insurance for further information. Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase.
What optional benefits has my employer selected as part of my Voluntary AD&D Insurance?
Am I eligible?
You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.
When can I enroll?
You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.
When is it effective?
Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.
Child Education Benefit Day Care Benefit Paralysis Benefit Seat Belt & Air Bag Spouse Education Benefit
You can purchase Voluntary Accidental Death and Dismemberment Insurance in increments of $10,000.
How much Voluntary AD&D Insurance can I purchase?
The maximum amount you can purchase cannot be more than 10 times your annual salary or $500,000. Salary is as defined in The Hartford’s contract with your employer. 43
Voluntary AD&D Benefit Highlights Does my coverage reduce as I get older?
No.
Do I have to provide medical information to receive coverage?
No medical information is required. You are guaranteed the amount of coverage that you select, subject to maximum amounts defined in your policy.
What is a beneficiary?
Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding. You are automatically the beneficiary for any dependent coverage and for any AD&D losses other than life.
Are there other limitations to enrollment?
This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the insurance coverage that you have elected may not be in effect.
Voluntary Accidental Death and Dismemberment Insurance for your Dependents
You may also choose Voluntary Accidental Death and Dismemberment Insurance for your spouse and/or dependent child(ren). You may choose voluntary Accidental Death and Dismemberment Insurance for your spouse in the following amounts: 50% of the amount you select for yourself if you do not have any child(ren) whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy. 40% if you have child(ren) whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy. You may not elect coverage for your spouse if your spouse is already covered as an employee under this policy. You may choose guaranteed voluntary Accidental Death and Dismemberment Insurance for each child at least 15 days but under age 26 in the following amounts: 15% of the amount you select for yourself if you do not have a spouse whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy 10% if you have a spouse whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy
Important Details
As is standard with most insurance, this Voluntary Accidental Death and Dismemberment Insurance includes limitations and exclusions. Voluntary Accidental Death and Dismemberment Insurance does not cover losses caused by or contributed by: sickness; disease; or any treatment for either; any infection, except certain ones caused by an accidental cut or wound; intentionally self-inflicted injury, suicide or suicide attempt; war or act of war, whether declared or not; injury sustained while in the armed forces of any country or international authority; taking prescription or illegal drugs unless prescribed for or administered by a licensed physician; injury sustained while committing or attempting to commit a felony; the injured person’s intoxication. Other exclusions may apply depending upon the terms of your policy and other requirements. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.
This benefit highlights sheet is an overview of the general purposes of the Voluntary Accidental Death and Dismemberment Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the policy, the terms of the insurance policy apply.
44
Voluntary Life and AD&D Employee Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$100,000
$0.40 $0.40 $0.40 $0.60 $1.00 $1.50 $2.60 $4.00 $5.30 $8.60 $15.00 $27.20
$0.80 $0.80 $0.80 $1.20 $2.00 $3.00 $5.20 $8.00 $10.60 $17.20 $30.00 $54.40
$1.20 $1.20 $1.20 $1.80 $3.00 $4.50 $7.80 $12.00 $15.90 $25.80 $45.00 $81.60
$1.60 $1.60 $1.60 $2.40 $4.00 $6.00 $10.40 $16.00 $21.20 $34.40 $60.00 $108.80
$2.00 $2.00 $2.00 $3.00 $5.00 $7.50 $13.00 $20.00 $26.50 $43.00 $75.00 $136.00
$2.40 $2.40 $2.40 $3.60 $6.00 $9.00 $15.60 $24.00 $31.80 $51.60 $90.00 $163.20
$2.80 $2.80 $2.80 $4.20 $7.00 $10.50 $18.20 $28.00 $37.10 $60.20 $105.00 $190.40
$3.20 $3.20 $3.20 $4.80 $8.00 $12.00 $20.80 $32.00 $42.40 $68.80 $120.00 $217.60
$4.00 $4.00 $4.00 $6.00 $10.00 $15.00 $26.00 $40.00 $53.00 $86.00 $150.00 $272.00
Any amount over $150,000 will be medically underwritten. You must complete an Evidence of Insurability Form
Spouse Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$50,000
$0.20 $0.20 $0.20 $0.30 $0.50 $0.75 $1.30 $2.00 $2.65 $4.30 $7.50 $13.60
$0.40 $0.40 $0.40 $0.60 $1.00 $1.50 $2.60 $4.00 $5.30 $8.60 $15.00 $27.20
$0.60 $0.60 $0.60 $0.90 $1.50 $2.25 $3.90 $6.00 $7.95 $12.90 $22.50 $40.80
$0.80 $0.80 $0.80 $1.20 $2.00 $3.00 $5.20 $8.00 $10.60 $17.20 $30.00 $54.40
$1.00 $1.00 $1.00 $1.50 $2.50 $3.75 $6.50 $10.00 $13.25 $21.50 $37.50 $68.00
$1.20 $1.20 $1.20 $1.80 $3.00 $4.50 $7.80 $12.00 $15.90 $25.80 $45.00 $81.60
$1.40 $1.40 $1.40 $2.10 $3.50 $5.25 $9.10 $14.00 $18.55 $30.10 $52.50 $95.20
$1.60 $1.60 $1.60 $2.40 $4.00 $6.00 $10.40 $16.00 $21.20 $34.40 $60.00 $108.80
$2.00 $2.00 $2.00 $3.00 $5.00 $7.50 $13.00 $20.00 $26.50 $43.00 $75.00 $136.00
NOTE: Rates for Spouse based on Spouse’s Age Any amount over $50,000 will be medically underwritten. You must complete an Evidence of Insurability Form.
Child Life Rates Child(ren)
$10,000 $1.00
Stand Alone AD&D Employee Family
$10,000 $0.40 $0.60
$20,000 $0.80 $1.20
$30,000 $1.20 $1.80
$40,000 $1.60 $2.40
$50,000 $2.00 $3.00
$60,000 $2.40 $3.60
$70,000 $2.80 $4.20
$80,000 $3.20 $4.80
$100,000 $4.00 $6.00
NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING. THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000 (NOT TO EXCEED 5 TIMES YOUR ANNUAL SALARY). FOR SPOUSE ANY INCREMENT OF $5,000 UP TO $125,000 (NOT TO EXCEED 50% OF EMPLOYEE LIFE AMOUNT). FOR AD&D ANY INCREMENT OF $10,000 UP TO $500,000 (NOT TO EXCEED 10 TIMES YOUR ANNUAL SALARY). TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY ADD LEVELS TOGETHER. 45
5 STAR 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 46 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Individual Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 Nearly 85% of Americans say most people need life insurance; unfortunately only 62% have coverage and a staggering 33% say they don’t have enough life insurance, including one-fourth who already have life insurance coverage.** Nobody wants to be a statistic especially during a period of grief. That’s why 5Star Life Insurance Company developed its FPP policy - to ensure you and your loved ones are covered during a period of loss. Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.
47
Term Life with Terminal Illness and Quality of Life Rider
Age on App. Date 18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 48
$10,000
SEMI-MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $6.20 $10.23 $14.26 $18.29 $5.40 $7.01 $6.23 $10.29 $14.36 $18.42 $5.42 $7.04 $6.32 $10.46 $14.60 $18.75 $5.48 $7.14 $6.43 $10.68 $14.95 $19.21 $5.57 $7.28 $6.61 $11.04 $15.48 $19.92 $5.72 $7.49 $6.84 $11.51 $16.16 $20.83 $5.90 $7.77 $7.09 $12.00 $16.91 $21.83 $6.10 $8.07 $7.37 $12.57 $17.77 $22.96 $6.33 $8.40 $7.66 $13.15 $18.64 $24.12 $6.56 $8.75 $8.00 $13.84 $19.67 $25.51 $6.84 $9.16 $8.38 $14.59 $20.79 $27.00 $7.13 $9.62 $8.80 $15.44 $22.07 $28.71 $7.48 $10.13 $9.27 $16.37 $23.48 $30.59 $7.86 $10.69 $9.76 $17.35 $24.95 $32.54 $8.24 $11.28 $10.30 $18.44 $26.57 $34.71 $8.68 $11.93 $10.88 $19.61 $28.32 $37.05 $9.14 $12.63 $11.55 $20.92 $30.30 $39.67 $9.67 $13.42 $12.26 $22.35 $32.45 $42.55 $10.25 $14.28 $13.00 $23.83 $34.67 $45.50 $10.83 $15.16 $13.78 $25.40 $37.02 $48.62 $11.46 $16.10 $14.59 $27.02 $39.45 $51.88 $12.11 $17.08 $15.46 $28.75 $42.04 $55.34 $12.81 $18.12 $16.36 $30.57 $44.76 $58.96 $13.53 $19.20 $17.29 $32.39 $47.51 $62.62 $14.26 $20.31 $18.27 $34.38 $50.48 $66.58 $15.05 $21.49 $19.34 $36.52 $53.70 $70.87 $15.91 $22.78 $20.55 $38.94 $57.33 $75.71 $16.88 $24.23 $21.95 $41.73 $61.52 $81.29 $17.99 $25.90 $23.50 $44.83 $66.17 $87.50 $19.23 $27.76 $25.24 $48.31 $71.39 $94.46 $20.62 $29.86 $27.08 $52.00 $76.92 $101.84 $22.10 $32.07 $29.17 $56.17 $83.17 $110.17 $23.77 $34.56 $31.33 $60.48 $89.64 $118.80 $25.50 $37.16 $33.52 $64.88 $96.23 $127.58 $27.25 $39.79 $35.78 $69.40 $103.01 $136.62 $29.06 $42.50 $38.15 $74.13 $110.10 $146.08 $30.95 $45.34 $40.60 $79.02 $117.45 $155.88 $32.91 $48.28 $43.15 $84.14 $125.14 $166.13 $34.96 $51.35 $45.89 $89.61 $133.33 $177.05 $37.14 $54.63 $48.86 $95.54 $142.23 $188.92 $39.51 $58.19 $52.16 $102.17 $152.17 $202.17 $42.17 $62.16
Term Life with Terminal Illness and Quality of Life Rider
Age on App. Date 66* 67* 68* 69* 70*
$10,000
MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $52.91 $103.65 $154.39 $205.13 $42.76 $63.05 $57.06 $111.96 $166.85 $221.75 $46.08 $68.04 $61.79 $121.42 $181.04 $240.67 $49.87 $73.72 $67.16 $132.15 $197.14 $262.13 $54.16 $80.15 $73.21 $144.25 $215.29 $286.33 $59.00 $87.42
*Quality of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 15 days to age 24 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.
49
VOYA
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 50 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
Critical Illness What is Cri cal Illness Insurance? Cri cal Illness Insurance pays a lump‐sum benefit if you are diagnosed a er your effec ve date of coverage with a covered illness or condi on listed below. Please review cer ficates of coverage for any limita ons that may apply. Cri cal Illness Insurance is a limited benefit policy. It is not health insurance and does not sa sfy the requirement of minimum essen al coverage under the Affordable Care Act. Features of Cri cal Illness Insurance include: Guaranteed Issue: No medical ques ons or tests required for coverage. Flexible: You can use the benefit money for any purpose you like. Portable: Should you leave your current employer or re re, you can take your coverage with you.
What benefits are available? Base Module Heart a ack Stroke Coronary artery bypass coronary obstruc on (25%) Coma Major organ failure Permanent paralysis End stage renal (kidney) failure Module A Benign brain tumor Deafness Occupa onal HIV Blindness
What addi onal benefits does my Cri cal Illness Insurance include? The benefits listed below are included with your Cri cal Illness coverage. There may be some varia on by state. For a list of standard exclusions and limita ons, please refer to the end of this document. For a complete descrip on of your available benefits, exclusions and limita ons, see your cer ficate of insurance and any riders. Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. Your annual benefit amount is $50 for comple ng a health screening test. Your spouse’s annual benefit amount is $50. The benefit for child coverage is 50% of your benefit amount per child with an annual maximum of $100 for all children.
Who is eligible for Cri cal Illness Insurance?
You — all ac ve employees working 20+ hours per week. You may purchase a $5,000‐$30,000 in $5,000 increments Maximum Cri cal Illness Benefit. Your spouse — under age 70. Coverage is available only if employee coverage is elected. You may also purchase a $5,000‐$15,000 in $5,000 increments Maximum Cri cal Illness Benefit. Your children — to age 26. Coverage is available only if employee coverage is elected. You may also purchase a $1,000, $2,500, $5,000 or $10,000 Maximum Cri cal Illness Benefit for each covered child. In addi on, there are benefits if your children are diagnosed a er the benefit’s effec ve date with: Down syndrome, cerebral palsy, cys c fibrosis and congenital birth defects.
How many mes can I receive a benefit? Usually you are only able to receive the Maximum Specified Disease Benefit once for each covered condi on, but: Your plan includes the Recurrence Benefit, which allows you to receive a benefit for the same condi on a second me. In order for the second occurrence of the illness to be covered, it must occur a er 12 consecu ve months without the occurrence of any covered cri cal illness named in your cer ficate, including the illness from the first benefit payment. If you have reached the benefit limit by receiving the maximum benefit for each covered condi on, you may choose to end your coverage; however, if you have coverage for your spouse and/or children, you must con nue your coverage in order to keep their coverage ac ve. Please see your cer ficate of coverage for details.
51
Critical Illness How much does Critical Illness Insurance cost? See the chart below for the premium amounts.
Employee Coverage—Uni-Tobacco Semi-Monthly Rates (24 Pay Periods) Includes Wellness Benefit Rider Issue $5,000 Age Under 30 $1.35 30-39 $1.60 40-49 $2.75 50-59
$4.45
60-64
$6.20
65-69
$8.55
70+
$12.30
$10,000
$15,000
$20,000
$25,000
$30,000
$2.70 $3.20
$4.05 $4.80 $8.25
$5.40 $6.40 $11.00
$6.75 $8.00 $13.75
$8.10 $9.60 $16.50
$8.90 $12.40
$13.35
$17.80
$22.25
$26.70
$18.60
$24.80
$31.00
$37.20
$17.10 $24.60
$25.65
$34.20
$42.75
$51.30
$36.90
$49.20
$61.50
$73.80
$5.50
Spouse Coverage—Uni-Tobacco Semi-Monthly Rates (24 Pay Periods) Includes Wellness Benefit Rider Issue $5,000 $10,000 $15,000 Age Under 30
$1.65
$3.30
$4.95
30-39 40-49 50-59 60-64 65-69 70+
$2.05 $3.55 $6.10 $7.95 $10.70 $14.80
$4.10 $7.10 $12.20 $15.90 $21.40 $29.60
$6.15 $10.65 $18.30 $23.85 $32.10 $44.40
Child(ren) Coverage Coverage Amount $1,000 $2,500 $5,000 $10,000
Semi-Monthly Rates (24 Pay Periods) $0.21 $0.53 $1.05 $2.05
Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*: Participation or attempt to participate in a felony or illegal activity. Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane. War or any act of war, whether declared or undeclared, other than acts of terrorism. Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion. Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.
Who do I contact with questions? For more information, please call the Voya Employee Benefits Customer Service Team at (877) 236-7536. This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Critical Illness Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-CI3-POL-12; Certificate Form #RL-CI3-CERT- 12; and Rider Forms: Spouse Critical Illness Rider Form #RL-CI3-SPR-12, Children's Critical Illness Rider Form #RLCI3-CHR-12, Wellness Benefit Rider Form #RL- CI3-WELL-12, and Recurrence Rider Form #RL- CI3-REC-12 Form numbers, provisions and availability may vary by state.
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Critical Illness
53
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 TO‌ 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 54 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
FSA (Flexible Spending Account) NBS Flexcard You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.
NBS Prepaid MasterCard® Debit Card
New Plan Participants
When Will I Receive My Flex Card? Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of January. Don’t forget, Flex Cards Are Good For 3 Years!
NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: claims@nbsbenefits.com
NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.
FSA Annual Contribution Max:
DID YOU KNOW?
$2,600
Dependent Care Annual Max:
FSAs use tax-free funds to help pay for your Health Care Expenses.
$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 claim FAQs
For a list of sample expenses, please refer to the Burkburnett ISD benefit website: www.thebenfitshub.com/burkburnettisd 55
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.thebenfitshub.com/burkburnettisd
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What Happens If I Don’t Use All of My Funds by The End of the Plan Year (December 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.thebenfitshub.com/ burkburnettisd 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.
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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 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd
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 provides medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short.
MASA MTS for Employees Ensures...
NO health questions NO age limits for employee or spouse 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 $4.50 (semi-monthly, per employee only/family coverage.
Emergent Card Example:
“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
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WWW.MYBENEFITSHUB.COM/ BURKBURNETTISD 60