FORT WORTH ISD
BENEFIT GUIDE EFFECTIVE: 09/01/2019 - 8/31/2020 WWW.MYBENEFITSHUB.COM/FORTWORTHISD 1
Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) 7. Fort Worth ISD Rates TRS-ActiveCare, Scott & White HMO, FirstCare ALEX® Teladoc Telehealth EECU Health Savings Account (HSA) Higginbotham Flexible Spending Account (FSA) United Concordia Dental Indemnity Humana Dental DHMO and Advantage Humana Vision The Hartford Long Term Disability American Public Life Cancer MetLife Optional Life and AD&D Texas Life Permanent Life CHUBB Accident Texas Legal Services January Savings Plan MASA Medical Transportation 2
3 4-5 6-13 6 7 8 9 10 11 12-13 14-21 22 23 24-25 26-39 40-41 42-51 52-55 56-71 72-75 76-89 90-93 94-95 96-99 100-101 102-104
FLIP TO... PG. 4
HOW TO ENROLL
PG. 6
SUMMARY PAGES
PG. 12
YOUR BENEFITS
Benefit Contact Information FINANCIAL BENEFIT SERVICES
FLEXIBLE SPENDING ACCOUNT
HEALTH SAVINGS ACCOUNT
Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/fortworthisd
Higginbotham P: (866) 419-3519 F: (817) 882-9267 www.mywealthcareonline.com/ higginbotham
EECU (817) 882-0800 www.eecu.org
FWISD BENEFITS OFFICE
DENTAL DHMO
DENTAL INDEMNITY
(817) 814-2240 www.fwisd.org Login Help Desk: (817) 814-HELP (4357) Email: benefits@fwisd.org
Group # 573701 Humana (800) 979-4760 www.humanadental.com
Group # 821479-000/001/002/003 United Concordia (800) 332-0366 www.ucci.com
TRS-ACTIVECARE MEDICAL
DENTAL ADVANTAGE
COBRA (DENTAL, VISION)
Aetna/Caremark (800) 222-9205 www.trsactivecareaetna.com
Group # 573701 Humana (800) 979-4760 www.humanadental.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
SCOTT & WHITE HMO MEDICAL
LEGAL SERVICES
COBRA (MEDICAL)
Scott & White (800) 321-7947 www.trs.swhp.org
Texas Legal (800) 252-9346 www.texaslegal.org
BSwift (833) 682-8972
FIRSTCARE MEDICAL
PERMANENT LIFE
HIGGINBOTHAM
FirstCare (800) 884-4901 www.firstcare.com/trs
Texas Life (817) 545-3900 ext. 102 www.texaslife.com
Higginbotham (817) 347-7031 www.higginbotham.net
OPTIONAL LIFE AND AD&D
DISABILITY
403(B) PLAN / 457 PLAN
Group # 122673-1-G MetLife (800) 638-6420 www.metlife.com
Group # 395332 The Hartford (866) 278-2655 www.thehartfordatwork.com
TCG Administrators (800) 943-9179 www.tcgservices.com
VISION
CANCER
JANUARY SAVINGS PLAN
Humana (866) 537-0229 www.humanavisioncare.com
Group # 18296 American Public Life (800) 256-8606 www.ampublic.com
Fort Worth ISD Payroll Department (817) 814-2180 www.fwisd.org
MEDICAL TRANSPORTATION MASA (800) 423-3226 www.masamts.com
ACCIDENT Group # BKRC671 CHUBB (866) 445-8874 www.combinedinsurance.com/us-en/ Corporate/Abou-Chubb.aspx 3
MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS FWISD” to 313131 and get access to everything you need to complete your benefits enrollment:
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•
Benefit Information
•
Online Support
•
Interactive Tools
•
And more.
Text “FBS FWISD” to 313131 OR SCAN
How to Log In
1 BENEFIT INFO
INTERACTIVE TOOLS
2 3
www.mybenefitshub.com/fortworthisd
CLICK LOGIN
ENTER USERNAME & PASSWORD Benefits are available for spouses (including same sex). If you have any questions, please contact benefits@fwisd.org or (817) 8142240.
Username and Password: Please use your district username and ONLINE SUPPORT
password to login.
For assistance logging into the enrollment system, please contact the FWISD Help Desk at 817-814-HELP (4357). Supported Browsers Google Chrome Microsoft Internet Explorer (7.0 or Later) Mozilla Firefox (3.5 or Later) 5
Annual Benefit Enrollment
SUMMARY PAGES
Benefit Updates - What’s New: •
All of the TRS medical plans will experience a rate increase effective 09/01/2019. ActiveCare 2 will no longer be available for new enrollees, however, current participants may elect to remain on the plan. The deductibles for ActiveCare 1 HD have increased as well • as the out of pocket maximum. The deductibles for ActiveCare Select will remain the same for the upcoming plan year. As a reminder, ActiveCare 1 HD & ActiveCare 2 have In Network and Out of Network Deductibles. Copays for ActiveCare Select and ActiveCare 2 have increased. For more info on plan design changes for all TRS ActiveCare plans, please • visit www.trsactivecareaetna.com.
•
Fort Worth ISD offers employees who are enrolled in a high deductible health care plan the opportunity to contribute to an HSA to pay for eligible medical, dental and vision expenses. Individual maximum contribution is $3,500 and Family maximum contribution is $7,000 per year. If you are actively participating in a HSA your FSA will be limited to only dental and vision. Make sure to login and complete a walkthrough if you are wanting this benefit for the 2019-20 plan year, it is not automatically renewed.
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Online Benefit Portal: www.mybenefitshub.com/ fortworthisd. You have access to benefit information 24/7 on the employee benefit portal provided. You can
• • • •
review and print the consolidated enrollment form or benefit guide, download claim forms and plan summaries, links to carrier websites and provider searches. MetLife Optional Life and AD&D coverage is available for employees and their dependents. Please note that if you are electing an amount over the Guarantee Issue, you will need to submit a Statement of Health within 30 days after your enrollment period has expired. Fort Worth ISD is providing employees the option to enroll in the January Savings Plan. Voluntary enrollment in the January Savings Plan will only be allowed during Open Enrollment only. No interest will be earned on the deduction amounts. There will be no early disbursements of funds once you enroll in the plan. Disbursement of the total amount you elected to deduct will be returned on January 10, 2020.
Login and complete your benefit enrollment from 07/22/2019 - 08/22/2019 Login assistance is available by calling the FWISD Help Desk at 817-814-HELP (4357) Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 Monday-Thursday 8am-5:30pm, Friday 8am-3pm. 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 STATUS (CIS):
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 the event and meet with your Benefit 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.
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 Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Government Programs
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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. Changes are not permitted during the plan year (outside of
For benefit summaries and claim forms, go to your school district’s benefit portal:
annual enrollment) unless a Section 125 qualifying event occurs.
www.mybenefitshub.com/fortworthisd. Click on the benefit plan you need information on (i.e., Dental) and you can find
•
the forms you need under the Benefits and Forms section.
Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.
How can I find a Network Provider?
• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.
•
Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within 31 calendar days from your date of hire. Failure to complete elections during this time frame will
result in forfeiture of coverage.
For benefit summaries and claim forms, go to your school district’s benefit portal: www.mybenefitshub.com/fortworthisd. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits department or you can call Financial Benefit Services at 866-914-5202 for assistance. 8
SUMMARY PAGES
Employee Eligibility Requirements Medical and Supplemental Benefits: Employees who are active
Dependent Eligibility Requirements
contributing TRS members are eligible for all benefits. Employees
You can cover eligible dependent children under a benefit
who are not active contributing TRS members are eligible to participate in TRS ActiveCare. Eligibility criteria may be found at
that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below.
www.fwisd.org. Click on departments, click on benefits, then
Dependents cannot be double covered by married spouses
select Eligibility. Benefits eligible employees must be actively at
within the Fort Worth ISD or as both employees and
work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions
dependents.
of your job on the first day of work concurrent with the plan
COBRA Administrator:
effective date. For example, if your 2019 benefits become effective on September 1, 2019, you must be actively-at-work on
National Benefit Services (NBS) (800) 274-0503
September 1, 2019 to be eligible for your new benefits. PLAN
CARRIER
MAXIMUM AGE
CONTINUATION
Medical
Aetna
26
COBRA—Aetna
Dental
United Concordia
26
COBRA—NBS
Dental
Humana
26
COBRA—NBS
Vision
Humana
26
COBRA—NBS
Disability
The Hartford
N/A
N/A
Basic Life
MetLife
N/A
Conversion*
Voluntary Life
MetLife
26
Conversion*
AD&D
MetLife
26
Individual Life
Texas Life
26
Medical Flex (FSA)
Higginbotham
N/A Contact TX Life for direct pay* COBRA—NBS
Dependent Care
Higginbotham
Accident
CHUBB
Health Savings Account
EECU
Cancer
APL
Medical Transportation
MASA
IRS Dependent 12 or younger or qualified individual unable to care for themselves & claimed as a N/A dependent on your taxes 26 Contact CHUBB for direct pay IRS Dependent covered Contact EECU on your HDHP for direct pay 26 Conversion* Complete application on 26 benefits website to continue Platinum plan
* Contact Carrier within 30 days of loss.
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 Benefit Administrator to request a continuation of coverage. 9
Helpful Definitions
SUMMARY PAGES
Actively at Work
In-Network
You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual
Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.
places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2019 please notify your benefits administrator.
Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.
Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.
Calendar Year January 1st through December 31st
Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Guaranteed Issue (GI) 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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Out-of-Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.
Plan Year September 1st through August 31st
Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
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 taxfree.
TRS-ActiveCare 1-HD Employee Individual
All employers Employee only Employer
High deductible health plan
None
$3,500 single (2019) $7,000 family (2019)
$2,700
Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).
Not permitted
Year-to-year rollover of account balance?
Yes
No. Remaining balances are available through October 31, 2020.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
Description
Employer Eligibility Contribution Source Account Owner Underlying Insurance Requirement Maximum Contribution
Permissible Use Of Funds
FLIP TO FOR HSA INFORMATION
PG. 24
FLIP TO FOR FSA INFORMATION
PG. 26 11
Fort Worth ISD Rates
SUMMARY PAGES
Plan Year September 1, 2019 - August 31, 2020
UNITED CONCORDIA DENTAL INDEMNITY Tier Emp Only Emp + Spouse Emp + Children Emp + Family
12 Pay Rates $41.35 $83.22 $92.34 $134.02
18 Pay Rates $27.57 $55.48 $61.56 $89.35
24 Pay Rates $20.68 $41.61 $46.17 $67.01
HUMANA DENTAL Managed Care Plan Primary Dentist Required Tier Emp Only Emp + Spouse Emp + Children Emp + Family
12 Pay Rates $12.66 $22.60 $23.96 $31.18
18 Pay Rates $8.44 $15.07 $15.97 $20.79
24 Pay Rates $6.33 $11.30 $11.98 $15.59
Advantage Plan Services Within Network Tier Emp Only Emp + Spouse Emp + Children Emp + Family
12 Pay Rates $18.70 $38.26 $38.88 $63.90
18 Pay Rates $12.47 $25.51 $25.92 $42.60
24 Pay Rates $9.35 $19.13 $19.44 $31.95
HUMANA VISION Tier Emp Only Emp + Spouse Emp + Children Emp + Family
12 Pay Rates $6.22 $12.45 $11.84 $18.60
18 Pay Rates $4.15 $8.30 $7.89 $12.40
24 Pay Rates $3.11 $6.23 $5.92 $9.30
APL CANCER
THE HARTFORD LONG TERM DISABILITY Ages
Monthly Benefit—Premium Option
$200 $300 $400 Under Age 30 $5.64 $8.46 $11.28 Ages 30-34 $6.72 $10.08 $13.44 Ages 35-39 $8.14 $12.21 $16.28 Ages 40-44 $8.98 $13.47 $17.96 Ages 45-49 $10.36 $15.54 $20.72 Ages 50-54 $12.94 $19.41 $25.88 Ages 55-59 $12.98 $19.47 $25.96 Premium Option Schedule for disability caused by injury or sickness: Age Disabled Benefits Payable Prior to Age 60 To Age 65 Age 60—64 60 months Age 65—67 To Age 70 Age 68 and older 24 months Select Option Schedule for disability caused by injury: Age Disabled Benefits Payable Prior to Age 60 To Age 65 Age 60—64 60 months Age 65—67 To Age 70 Age 68 and older 24 months Select Option Schedule for disability caused by sickness: Age Disabled Benefits Payable Prior to Age 65 5 Years Age 65—69 To Age 70, but not less than 1 yr Age 69 and older 1 year
HIGGINBOTHAM FLEXIBLE SPENDING ACCOUNT
Plan 1 EE Only EE + Spouse EE + Children EE + Family
12 Pay Rates $15.66 $33.38 $18.30 $36.02
18 Pay Rates $10.44 $22.25 $12.20 $24.01
24 Pay Rates $7.83 $16.69 $9.15 $18.01
Plan 2 EE Only EE + Spouse EE + Children EE + Family
12 Pay Rates $25.00 $53.84 $29.10 $57.98
18 Pay Rates $16.67 $35.89 $19.40 $38.65
24 Pay Rates $12.50 $26.92 $14.55 $28.99
Healthcare Reimbursement Maximum: $2,700 Dependent Care Reimbursement Maximum: $2,500 or $5,000 (Dependent Care Maximum is based on Marital Status)
EECU HEALTH SAVINGS ACCOUNT Individual Maximum Family Maximum
CHUBB ACCIDENT
MASA MEDICAL TRANSPORTATION
Employee and Family Coverage 12
Emergent Plus
Platinum
$14/mo
$39/mo
$3,500 $7,000
Employee Only Employee + Spouse Employee + Children Employee + Family
Gold Plan $9.40 $17.16 $19.32 $27.08
Diamond Plan $16.48 $30.12 $33.64 $47.28
SUMMARY PAGES
METLIFE OPTIONAL LIFE AND AD&D 12 Checks Age on Sept. 1 Under 40 40-49 50-54 55-59 60-64 65+ Age on Sept. 1 Under 40 40-49 50-54 55-59 60-64 65+
20K 1.52 4.70 6.22 12.50 17.58 19.12 90K 6.84 21.15 27.99 56.25 79.11 86.04
30K 2.28 7.05 9.33 18.75 26.37 28.68 100K 7.60 23.50 31.10 62.50 87.90 95.60
40K 3.04 9.40 12.44 25.00 35.16 38.24 120K 9.12 28.20 37.32 75.00 105.48 114.72
50K 3.80 11.75 15.55 31.25 43.95 47.80 140K 10.64 32.90 43.54 87.50 123.06 133.84
Age on Sept. 1 Under 40 40-49 50-54 55-59 60-64 65+ Age on Sept. 1 Under 40 40-49 50-54 55-59 60-64 65+
20K 1.01 3.13 4.15 8.33 11.72 12.75 90K 4.56 14.10 18.66 37.50 52.74 57.36
30K 1.52 4.70 6.22 12.50 17.58 19.12 100K 5.07 15.67 20.73 41.67 58.60 63.73
40K 2.03 6.27 8.29 16.67 23.44 25.49 120K 6.08 18.80 24.88 50.00 70.32 76.48
50K 2.53 7.83 10.37 20.84 29.30 31.87 140K 7.09 21.93 29.03 58.34 82.04 89.23
Age on Sept. 1 Under 40 40-49 50-54 55-59 60-64 65+ Age on Sept. 1 Under 40 40-49 50-54 55-59 60-64 65+
20K 0.76 2.35 3.11 6.25 8.79 9.56 90K 3.42 10.58 14.00 28.13 39.56 43.02
30K 1.14 3.53 4.67 9.38 13.19 14.34 100K 3.80 11.75 15.55 31.25 43.95 47.80
40K 1.52 4.70 6.22 12.50 17.58 19.12 120K 4.56 14.10 18.66 37.50 52.74 57.36
50K 1.90 5.88 7.78 15.63 21.98 23.90 140K 5.32 16.45 21.77 43.75 61.53 66.92
60K 4.56 14.10 18.66 37.50 52.74 57.36 160K 12.16 37.60 49.76 100.00 140.64 152.96
70K 5.32 16.45 21.77 43.75 61.53 66.92 200K 15.20 47.00 62.20 125.00 175.80 191.20
80K 6.08 18.80 24.88 50.00 70.32 76.48 250K 19.00 58.75 77.75 156.25 219.75 239.00
Dependent Life Plan
Plan C (20K Employee Minimum) 20K Spouse 10K Eligible Children Per Paycheck: $5.00 per employee
Plan D (30K Employee Minimum) 30K Spouse 15K Eligible Children Per Paycheck: $9.38 per employee
18 Checks 60K 3.04 9.40 12.44 25.00 35.16 38.24 160K 8.11 25.07 33.17 66.67 93.76 101.97
70K 3.55 10.97 14.51 29.17 41.02 44.61 200K 10.13 31.33 41.47 83.33 117.20 127.47
80K 4.05 12.53 16.59 33.33 46.88 50.99 250K 12.67 39.17 51.83 104.17 146.50 159.33
Dependent Life Plan
Plan C (20K Employee Minimum) 20K Spouse 10K Eligible Children Per Paycheck: $3.33 per employee
Plan D (30K Employee Minimum) 30K Spouse 15K Eligible Children Per Paycheck: $6.25 per employee
24 Checks 60K 2.28 7.05 9.33 18.75 26.37 28.68 160K 6.08 18.80 24.88 50.00 70.32 76.48
70K 2.66 8.23 10.89 21.88 30.77 33.46 200K 7.60 23.50 31.10 62.50 87.90 95.60
80K 3.04 9.40 12.44 25.00 35.16 38.24 250K 9.50 29.38 38.88 78.13 109.88 119.50
Dependent Life Plan Plan C (20K Employee Minimum) 20K Spouse 10K Eligible Children Per Paycheck: $2.50 per employee
Plan D (30K Employee Minimum) 30K Spouse 15K Eligible Children Per Paycheck: $4.69 per employee 13
ACTIVECARE / SCOTT & WHITE / FIRSTCARE
Medical
About this Benefit
YOUR BENEFITS PACKAGE
DID YOU KNOW?
Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis More than 70% of adults across the United States are already being diagnosed with a chronic disease.
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 14 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
TRS Medical Insurance Rates– 2019-2020 ActiveCare 1-HD
ActiveCare Select
ActiveCare 2
Scott & White HMO
FirstCare
12 Checks Employee Only
$91.00
$269.00
$565.00
$271.54
$273.50
Employee + Spouse
$779.00
$1,080.00
$1,733.00
$1,019.58
$1,129.52
Employee + Child(ren)
$435.00
$615.00
$980.00
$589.76
$605.16
$1,128.00
$1,431.00
$2,102.00
$1,170.28
$1,167.80
Spousal-Both Employees of FWISD
$841.00
$1,144.00
$1,815.00
$883.28
$880.80
Spousal-One Employee of FWISD and one Other District
$420.50
$572.00
$907.50
$441.64
$440.40
Employee + Family
18 Checks Employee Only
$60.67
$179.33
$376.67
$181.03
$182.33
Employee + Spouse
$519.33
$720.00
$1,155.33
$679.72
$753.01
Employee + Child(ren)
$290.00
$410.00
$653.33
$393.17
$403.44
Employee + Family
$752.00
$954.00
$1,401.33
$780.19
$778.53
Spousal-Both Employees of FWISD
$560.67
$762.67
$1,210.00
$588.85
$587.20
Spousal-One Employee of FWISD and one Other District
$280.33
$381.34
$605.00
$294.43
$293.60
24 Checks Employee Only
$45.50
$134.50
$282.50
$135.77
$136.75
Employee + Spouse
$389.50
$540.00
$866.50
$509.79
$564.76
Employee + Child(ren)
$217.50
$307.50
$490.00
$294.88
$302.58
Employee + Family
$564.00
$715.50
$1,051.00
$585.14
$583.90
Spousal-Both Employees of FWISD
$420.50
$572.00
$907.50
$441.64
$440.40
Spousal-One Employee of FWISD and one Other District
$210.25
$286.00
$453.75
$220.82
$220.20
TRS-Active Care Rates for employees who do not contribute to TRS 12 checks Employee Only
Employee + Spouse Employee + Child(ren) Employee + Family
$378.00
$556.00
$852.00
$558.54
$560.50
$1,066.00
$1,367.00
$2,020.00
$1,306.58
$1,416.52
$722.00
$902.00
$1,267.00
$876.76
$892.16
$1,415.00
$1,718.00
$2,389.00
$1,457.28
$1,454.80
18 Checks Employee Only
$252.00
$370.67
$568.00
$372.36
$373.67
Employee + Spouse
$710.67
$911.33
$1,346.67
$871.05
$944.35
Employee + Child(ren)
$481.33
$601.33
$844.67
$584.51
$594.77
Employee + Family
$943.33
$1,145.33
$1,592.67
$971.52
$969.87
24 checks
Employee Only
$189.00
$278.00
$426.00
$279.27
$280.25
Employee + Spouse
$533.00
$683.50
$1,010.00
$653.29
$708.26
Employee + Child(ren)
$361.00
$451.00
$633.50
$438.38
$446.08
Employee + Family
$707.50
$859.00
$1,194.50
$728.64
$727.40 15
2019 – 20 TRS-ActiveCare Plan Highlights Effective Sept. 1, 2019 through Aug. 31, 2020 | In-Network Level of Benefits1 TRS-ActiveCare 1-HD
TRS-ActiveCare Select or TRS-ActiveCare Select Whole Health
TRS-ActiveCare 2
(Baptist Health System and HealthTexas Medical Group; Baylor Scott and White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)
NOTE: If you’re currently enrolled in TRSActiveCare 2, you can remain in this plan. However, as of Sept. 1, 2018, TRS-ActiveCare 2 is closed to new enrollees.
$500 copay per visit plus 20% after deductible
$500 copay per visit plus 20% after deductible
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 Facility Charges Only (preauthorization required) In-Network
Out-of-Network
Urgent Care Freestanding Emergency Room Participant pays
$500 copay per visit plus 20% after deductible
Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery (only covered if performed at an 10Q facility) Physician charges; Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist)Participant pays Annual Hearing Examination Participant pays Preventive Care Some examples of preventive care frequency and services: • • • •
Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smoking cessation counseling – 8 visits per 12 months Well-child care – unlimited up to age 12
• • •
Colonoscopy – one every 10 years age 50 and over Healthy diet/obesity counseling – unlimited to age 22; age 22 and over – 26 visits per 12 months Well woman exam & pap smear – annually age 18 and over
• •
Prostate cancer screening – one per year age 50 and over Breastfeeding support – six lactation counseling visits per 12 months
Note: Covered services under this benefit must be billed by the provider as “preventive care.” Non-network preventive care is not paid at 100%. If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the TRS-ActiveCare 1-HD and TRS-ActiveCare 2. There is no coverage for non-network services under the TRS-ActiveCare Select plan or TRS-ActiveCare Select Whole Health. For more information, please view the Benefits Booklet at www.trsactivecareaetna.com. TRS-ActiveCare is16 administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark
2019 – 20 TRS-ActiveCare Plan Highlights TRS-ActiveCare 1-HD
TRS-ActiveCare Select or ActiveCare Select Whole Health
TRS- ActiveCare 2
(Baptist Health System and HealthTexas Medical Group; Baylor Scott and White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)
NOTE: If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan. However, as of Sept. 1, 2018, TRS-ActiveCare 2 is closed to new enrollees.
Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after deductible, except for certain generic preventive $15 copay drugs that are covered at 100%.2 25% coinsurance after deductible3 25% coinsurance (min. $404; max. $80)3 50% coinsurance after deductible3 50% coinsurance3 Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)5 20% coinsurance after deductible $45 copay 25% coinsurance after deductible3 25% coinsurance (min. $1054; max. $210)3 3 50% coinsurance after deductible 50% coinsurance3 Specialty Medications (up to a 31-day supply)
$20 copay 25% coinsurance (min. $404; max. $80)3 50% coinsurance (min. $1004; max. $200)3 $45 copay 25% coinsurance (min. $1054; max. $210)3 50% coinsurance (min. $2154; max. $430)3
20% coinsurance (min. $2004 , max $900)
Specialty Medications
20% coinsurance after deductible 20% coinsurance Short-Term Supply of a Maintenance Medication at Retail Location up to a 31-day supply
The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy, they will be charged the coinsurance and copays in the rows below. Participants can save more over the plan year by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location.
Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand
20% coinsurance after deductible 25% coinsurance after deductible3 50% coinsurance after deductible3
$30 copay 25% coinsurance (min. $604; max. $120)3 50% coinsurance3
$35 copay 25% coinsurance (min. $604; max. $120)3 50% coinsurance (min. $1054; max. $210)3
What is a maintenance medication? Maintenance medications 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 $15, then you will pay $30 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 $180 over the year by filling a 90 -day supply.
A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the TRS-ActiveCare Select or TRS-ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. 2 For TRS-ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 – individual, $5,500 – family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.
Monthly Premiums
Full monthly premium *
Premium with min. state/ district contribution**
$378
+Spouse +Children
+Family
Individual
Your Monthly Premium***
Full monthly premium *
Premium with min. state/ district contribution **
$153
$556
$1,066
$841
$722
$497
$1,415
$1,190
Your Monthly Premium***
Full monthly premium *
Premium with min. state/ district contribution **
$331
$852
$627
$1,367
$1,142
$2,020
$1,795
$902
$677
$1,267
$1,042
$1,718
$1,493
$2,389
$2,164
Your Monthly Premium***
* If you are not eligible for the state/district subsidy, you will pay the full monthly premium. Please contact your Benefits Administrator for your monthly premium. ** The premium after state, $75 and district, $150 contribution is the maximum you may pay per month. Ask your Benefits Administrator for your monthly cost. (This is the amount you will owe each month after all available subsidies are applied to your premium.) *** Completed by your benefits administrator. The state/district contribution may be greater than $225. 17
2019-2020 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Healthcare Services
Copay
Preventive Services
No Charge
Standard Lab and X-Ray
No Charge
Disease Management and Complex Case Management
No Charge
Well Child Care Annual Exams
No Charge
Immunizations (age appropriate)
No Charge
Plan Provisions
Copay
Annual Deductible
$950 Individual/ $2,850 Family
Annual out-of-pocket maximum (including medical and prescription copays and coinsurance)
Lifetime Paid Benefit Maximum
Outpatient Services
$7,450 Individual/ $14,900 Family (includes combined Medical and RX copays, deductibles and coinsurance)
None
Copay $20 copay
Primary Care1
(First Primary Care Visit for Illness - $0 Copay2) / $0 Copay for primary visit for dependents age 19 and under)
Specialty Care
$70 copay
Other Outpatient Services
20% after deductible3
Diagnostic/Radiology Procedures
20% after deductible
Eye Exam (one annually) Allergy Serum & Injections
No Charge 20% after deductible
Outpatient Surgery
$150 copay and 20% of charges after deductible
Maternity Care
Copay
Prenatal Care Inpatient Delivery
Inpatient Services Overnight hospital stay: includes all medical services including semi -private room or intensive care
Diagnostic & Therapeutic Services Physical and Speech Therapy Manipulative Therapy5
Equipment and Supplies Preferred Diabetic Supplies and Equipment Non-Preferred Diabetic Supplies and Equipment Durable Medical Equipment/ Prosthetics 18
No Charge $150 per day4 and 20% of charges after deductible
Copay $150 per day4 and 20% of charges after deductible
Copay $70 copay 20% without office visit $40 plus 20% with office visit
Copay $5/$12.50 copay; no deductible 30% after Rx deductible 20% after deductible
2019-2020 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services
Copay
Home Healthcare Visit
$70 copay
Worldwide Emergency Care
Copay
Nurse Advice Line
1-877-505-7947
Online Services
No Charge — go to trs.swhp.org
After-Hours Primary Care Clinics
$20 copay
Ambulance and Helicopter
$40 copay and 20% of charges after deductible
Emergency Room6
$500 copay after deductible
Urgent Care Facility
$50 copay
Prescription Drugs
Copay
Annual Benefit Maximum
Unlimited
Rx Deductible
$150
Does not apply to preferred generic drugs
Ask an SWHP Pharmacy representative how to save money on your prescriptions.
Maintenance Quantity (Up to a 30-day supply)
(Up to a 90-day supply) Available at BSW Pharmacies, in-network retail pharmacies and mail order
$5 copay
$12.50 copay
Preferred Brand
30% after Rx deductible
30% after Rx deductible
Non-Preferred
50% after Rx deductible
50% after Rx deductible
Preferred Generic
Online Refills Mail Order
Specialty Medications
Retail Quantity
trs.swhp.org BSWH: 1-817-388-3090 OptumRx: 1-855-205-9182
Copay Tier 1: 15% after Rx deductible
(Up to a 30-day supply)
Tier 2: 15% after Rx deductible
Tier 3: 25% after Rx deductible 1
Including all services billed with office visit Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after deductible 5 35 maximum visit per year 6 Copay waived if admitted within 24 hours 2
The SWHP MOMS Program provides you with professional nurses who are notified of the delivery of your baby. These licensed professionals will contact you after you return home and help you with everything from the general well-being of both you and your baby, to breast/bottle feeding, to information on how to add your baby to your health plan.
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2019-2020 TRS-FirstCare Plan Highlights Plan Summary 2019 -2020 Medical Plan Year Deductible Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) Annual Maximum
$950 Individual; $2,850 Family $7,450 Individual; $14,900 Family Unlimited
Primary Care Provider (PCP) Office Visit • Includes routine lab/X-ray services, injectables, and supplies • Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance
$20 copayment
PCP Office Visit-Dependents, through age 19
$0 copayment
Specialist Office Visit • Includes routine lab/X-ray services • Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance
$70 copayment
Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening
No copayment
Surgical Procedures Performed in the Physician's Office Urgent Care
25% coinsurance1 $50 copayment
Emergency Room
$500 copayment1
Ambulance Air/Ground
25% coinsurance1
Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility, behavioral health (mental health/chemical dependency)
25% coinsurance1
Outpatient Services Facility charges, physician services, surgical procedures, observation unit
25% coinsurance1
MRI, CT Scan, PET Scan (Facility/Physician)
$250 copayment1
Diagnostic Tests Sleep study; Stress test; EKG; Ultrasound; Cardiac imaging; Genetic testing; Non-preventive Colonoscopy (Facility/Physician)
25% coinsurance1
Home Health Care Limited to 60 visits per plan year
25% coinsurance1
Hospice Care
25% coinsurance1
Skilled Nursing Facility Limited to 30 days per plan year
25% coinsurance1
Accidental Dental Care
25% coinsurance1
Durable Medical Equipment
25% coinsurance1
All Other Covered Services
25% coinsurance1
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Prescription Drug Plan Year Deductible
$150 Per Individual
Participating Retail Pharmacy (Standard drugs/30-day supply) • ACA Preventative • Preferred Generic • Preferred Brand • Non-preferred Brand/Non-preferred Generics • Specialty Medications Tier 1 and 2 Tier 3
$0 copayment $5 copayment 30% coinsurance2 50% coinsurance2
15% coinsurance2 25% coinsurance2
Maintenance (up to 90-day supply at BSW pharmacies, in-network retail, and mail order for maintenance eligible drugs) • • • • 1 2
$0 copayment $12.50 copayment 30% coinsurance2 50% coinsurance2
ACA Preventative Preferred Generic Preferred Brand Non-preferred Brand/Non-preferred Generics
Subject to medical deductible Subject to prescription drug deductible
Gross Monthly Cost for Coverage Effective September 1, 2019 - August 31, 2020 Coverage Category Employee only Employee and spouse Employee and child(ren) Employee and family
Total Cost* $560.50 $1,416.52 $892.16 $1,454.80
*District and state funds are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.
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ALEX® The Benefit Administrator’s Best Friend What is ALEX®?
How can I talk to ALEX?
ALEX is your personal TRS-ActiveCare benefits expert. ALEX is funny, speaks in plain English—not insurance-talk—and is available to help you and TRS-ActiveCare members figure out which ActiveCare plan will best serve you and your families’ needs (anonymously, of course).
ALEX is available from any computer with an internet connection – all you have to do is visit www.myalex.com/ trsactivecare to get started. Want to walk through your options with your family? You can talk to ALEX from your home computer or mobile device, 24 hours a day, 7 days a week.
Sounds great…but how does it work? How ALEX works is simple. All you have to do is log on and respond to ALEX’s questions. ALEX will prompt you for some basic information about you and your family, ask a few questions about how your personal situation (everything you say remains confidential, of course), and help you figure out what to choose based on your responses.
What else can ALEX do? • • • •
Help you and TRS-ActiveCare members understand and compare plan options Explain complicated health insurance terms in jargonfree language Show you how different plan features like deductibles, coinsurance and out-of-pocket maximums work Walk you through estimating tax savings with a health savings account (if you’re considering the ActiveCare 1-HD plan)
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Teladoc Talk to a Doctor Anytime Quality, affordable healthcare when and where you need it.
Teladoc™ is an added benefit that gives you 24/7/365 access to a national network of U.S. board-certified doctors and pediatricians through the convenience of phone consultations. Request a non-urgent consultation anytime, no matter where you happen to be.
With your consent, Teladoc is happy to provide information about your Teladoc consult to your primary care physician.
New to Teladoc?
www.Teladoc.com www.Facebook.com/Teladoc 1-800-Teladoc www.Teladoc.com/mobile
Select your medical plan below to learn more about Teladoc and set up your Teladoc account: If you are currently enrolled in one of the following medical plans, click the link below to set up your Teladoc account. • •
ActiveCare Select ActiveCare 2
www.teladoc.com If you are currently enrolled in one of the following medical plans, click the link below to set up your Teladoc account. •
ActiveCare 1-HD
https://member2.teladoc.com/aetna
When Can I Use Teladoc? Teladoc does not replace your primary care physician. It is a convenient and affordable option for quality care. • •
• •
When you need care now If you’re considering the ER or urgent care center for a nonemergency issue On vacation, on a business trip, or away from home For short-term prescription refills
Get the Care You Need Teladoc doctors can treat many medical conditions, including:
• • • • • • •
Meet Our Doctors Teladoc is simply a new way to access qualified doctors. All Teladoc doctors: • • • •
Are practicing PCPs, pediatricians, and family medicine physicians Average 15 years experience Are U.S. board-certified and licensed in your state Are credentialed every three years, meeting NCQA standards
Disclaimer: ©2016 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.
Cold & flu symptoms Allergies Bronchitis Urinary tract infection Respiratory infection Sinus problems And more!
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EECU
HSA (Health Savings Account)
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.
YOUR BENEFITS PACKAGE
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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 24 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
HSA (Health Savings Account) What is an HSA?
How to Use Your Funds
Health Savings Account (HSA) enables you to save for and conveniently pay for qualified healthcare expenses, while you earn tax-free interest and pay no monthly service fees. Opening a Health Savings Account provides both immediate and long term benefits. The money in your HSA is always yours, even if you change jobs, switch your health plan, become unemployed or retire. Your unused HSA balance rolls over from year to year. And best of all, HSAs have tax-free deposits, tax-free earnings and tax-free withdrawals. And after age 65, you can withdraw funds from your HSA penalty-free for any purpose*.
•
HSA Debit Card – use your EECU HSA Mastercard® debit card to pay healthcare providers at point-of-sale or by following the instructions provided on a bill from a medical provider.
•
Online Bill Pay – sign up, at eecu.org, and use EECU’s free online banking and bill pay to make payments to medical providers directly from your HSA. Online Transfers – use EECU’s online banking or mobile app; reimburse yourself for out-of-pocket expenses by making a transfer from your HSA to your personal checking or savings account. Check – optional HSA checks can be ordered upon request for a fee. You can use these checks to pay healthcare providers and suppliers.
EECU HSA Benefits •
•
Save money tax-free for healthcare expenses – contributions are not subject to federal income taxes and can be made by • you, your employer or a third party* • No monthly service fee – so you can save more and earn more • Earn competitive dividends on your entire balance – Save your receipts – for all qualified medical expenses. compounded daily and paid monthly from deposit to EECU does not verify eligibility. You are responsible for withdrawal making sure payments are for qualified medical expenses. • Conveniently pay for qualified healthcare expenses – with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available How To Manage Your Account upon request, for a nominal fee**) • Online - check your balance, pay healthcare providers and • Free online, mobile and branch access – allows you to arrange deposits; sign-up for online banking at actively manage your account however you prefer www.eecu.org. • Comprehensive service and support – to assist you in • Mobile - EECU’s mobile app allows you to manage your optimizing your healthcare saving and spending account on the go; download “EECU Mobile Banking” in • Federally insured – to at least $250,000 by NCUA Apple’s App Store and Google Play. • Contact Member Service – call 817-882-0800 for help with 2019 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,500 us online at eecu.org or use our secure email. Member Family: $7,000 Service is available Monday through Friday from 8:00am – Catch-Up Contributions: Accountholders who meet the 7:00pm CT, Saturdays from 9am – 1pm CT and closed on qualifications noted below are eligible to make an HSA Sunday. catch-up contribution of an additional $1,000. • Account Statements – monthly statements show all your • Health Savings accountholder account activity for that period. You can receive free online • Age 55 or older (regardless of when in the year an statements or pay $2 per printed statement. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation. Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.
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HIGGINBOTHAM
FSA (Flexible Spending Account)
YOUR BENEFITS PACKAGE
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. However, your plan contains a grace period provision through October 31, 2020.
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 FOR HSA VS. FSA COMPARISON
PG. 11
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 26 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
FSA (Flexible Spending Account) What is a Flexible Spending Account? A Flexible Spending Account is a benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. Then, during the year, you can use the funds in the account to pay for qualified expenses with untaxed dollars.
Why should I participate in the plan?
If I set aside part of my pay, won’t I make less money? NO. For every dollar you set aside to pay qualified expenses, you save FICA and federal income tax withholding. Your net take-home pay will increase by the tax you save. Plus, when you pay a qualified expense or receive a cash reimbursement, it’s TAX FREE.
Your biggest benefit is savings on payroll withholding taxes. You will save $25 to $40 on every $100 you budget to pay for qualified expenses.
Can I change my contribution during the year?
What expenses qualify for payment?
YES, but only in certain situations. For the Health FSA and Dependent Care FSA, you can change your election if you have a change in status or a change in your employment or the employment of your spouse or a dependent.
Most qualified expenses are for goods or services that you’ll buy anyway. They include health care costs such as co-pays, doctors’ fees, over-the-counter items and prescriptions, dental and eye care expenses and daycare expenses for dependents so you can work.
How do I know how much is available for me to spend and how do I file a claim? Your balance and claim forms are available 24/7 online at www.mywealthcareonline.com/higginbotham and all other details are always available online or by calling the Flex Hotline at 866-419-3519. Filing claims is easy. Just complete a claim form and attach a copy of the bill. Then, send it to us. Within a short time (usually less than 72 hours), you’ll receive your TAX-FREE reimbursement.
Must money be deposited in my account before I pay expenses or file a claim? NO. The entire annual amount you elect for the Health Care Spending Account (Health FSA) is available on the first day. However, only amounts contributed to date are available for the Dependent Care Spending Account (Dependent Care FSA).
What if I don’t use all the money in my account? Generally, contributions that are not used during the plan year are forfeited back to your employer, but changes to IRS may allow extra time to spend your money or to carryover up to $500. Check with your employer to learn your options.
What happens to my accounts if I terminate employment? You may request reimbursement for qualified expenses incurred prior to your termination date.
You do have the option to enroll in both a HSA and a FSA, however doing so will make your FSA a “Limited” FSA, which means it will only be available for dental and vision expenses. All medical expenses would be processed through your HSA.
I already have health insurance. Why should I participate in the Health FSA? The Health FSA is used to pay for expenses not covered by insurance. These include co-pays, over-the-counter medications, glasses, contacts, orthodontics and prescription drugs, just to name a few.
I don’t use my employer’s health insurance. Can I still save? YES. You can still set aside money (before taxes are taken out) to budget and pay for qualified expenses. Remember, a qualified expense paid from this plan cannot be eligible for reimbursement from another plan.
AS OF JANUARY 1, 2011: All over-the-counter items require a one-time physician’s prescription per plan year. 27
FSA (Flexible Spending Account) How Flexible Spending Accounts Work When you pay for these expenses with pre-tax dollars, you pay no federal income tax on your contributions. Your taxable income and your taxes are reduced. Here’s how it works:
Let’s say you earn $25,000 per year. And you are paid semi-monthly, Gross Earnings so each paycheck is for gross compensation of $1,041.67. You have Plan Contributions insurance premiums and other expenses eligible for payment Taxable Earnings through the Health FSA of $62.50 per pay period. Here is a Less Taxes comparison of what your paycheck looks like both with and without FICA the Flexible Spending Account. Federal
As you can see, when you pay for your expenses with pre-tax dollars, your net income is increased!
Eligible Expenses
****GAIN****
Without FSA
With FSA
$1,041.67 -0$1,041.67
$1,041.67 $62.50 $979.17
$79.69 $105.42
$74.91 $93.41
$856.56 $62.50
$810.85
$794.06
$810.85
$33.58 Monthly
$402.96 Annually
When you incur a medical, dental or vision expense, you will be reimbursed the “full” amount of the expense at that time, up to your yearly contribution election. EXAMPLE: You are going to contribute $500 for the plan year ($41.67 per month). On January 15, you visit your eye doctor and receive your exam and contact lenses for a total charge of $200.
Fax that receipt to Higginbotham and receive your full $200 back within 24-72 hours, even though you do not have the $200 in your account at that time.
You are entitled to the entire $500 from day one of your plan year.
Orthodontia Expenses If you are currently paying on an orthodontia contract for yourself, your spouse or your children, you can put that payment aside in your Health FSA and use the mySourceCard to make the payment each month to your orthodontist. All we need is a copy of your current contract and the first payment receipt made with the mySourceCard. Your monthly orthodontic payments will be substantiated automatically for the current plan year.
Your account balance and claim forms are available 24/7 online at www.mywealthcareonline.com/higginbotham All other general details are always available online or by calling the Flex Hotline at 866-419–3519
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FSA (Flexible Spending Account) Health Care Expenses That Qualify for Reimbursement NOTE: Only health care expenses NOT reimbursed by insurance can be claimed on a Flexible Spending Account plan. • • • • • • • •
• • • • • •
Acupuncture (excluding remedies and treatments prescribed by acupuncturist) Alcoholism treatment Ambulance Artificial limbs/teeth Chiropractors Christian Science Practitioner’s fees Contact lenses and solutions Co-payments (doctor, dental, vision, pharmacy) Costs of physical or mental illness confinement Crutches Deductibles Dental fees (cosmetic procedures not eligible) Dentures Diagnostic fees
• • • • • • • • • • • • • • • • •
Drug and medical supplies (syringes, needles, etc.) Endodontist fees Eye examination fees Eyeglasses prescribed by your doctor Eye surgery (cataracts, LASIK, etc.) Hearing devices and batteries Home health care Hospital bills Insulin Laboratory fees Laser eye surgery Obstetrics and fertility Office visits Oral surgery Orthodontic fees Orthopedic devices Osteopath fees
Health Care Expenses That Require a Physician’s Letter Listing a Medical Condition Making the Item Necessary • • • • • • • • • • •
Bedpans Ring Cushions Boost/Pediasure Foot spa Massagers Massages Reconstructive surgery in connection with birth defect, disease or accident Special school for disabled child Therapeutic support gloves Weight loss program fees and over-the-counter drugs pertaining to a specific disease Wigs for hair loss caused by disease
• • •
• • • • • • • • • • • •
Oxygen Periodontist fees Physician fees (cosmetic procedures not eligible) Podiatrist fees Prescribed medicines Psychiatric care Psychologist and psychiatrist fees Radiology Routine physicals and other nondiagnostic services or treatments Smoking cessation over-the-counter drugs Smoking cessation programs Surgical fees Wheelchair Vitamins with doctor’s letter X-rays and MRI
Health Care Expenses That Do Not Qualify for Reimbursement • • • • • • • • •
Cosmetic surgery, procedures and/or medications Dental bleaching and electronic toothbrushes Hair restoration (procedures, drugs or medications) Health club or gym memberships for general health Marriage and family counseling Weight loss program food supplements Weight loss programs for general health or appearance Mail order prescriptions from another country Premiums you or your spouse pay for insurance coverage (payroll-deducted premiums sponsored by your employer are eligible under the Premium Only Plan)
Reimbursements are as simple as 1, 2, 3! • • •
Complete a claim form Provide required documentation Submit by email or mail
29
FSA (Flexible Spending Account) Over-the-Counter Drugs That Qualify for Reimbursement Over-the-counter drugs require a physician’s prescription. •
• •
•
•
Antiseptics Antiseptic wash or ointment for cuts or scrapes Benzocaine swabs Boric acid powder First aid wipes Iodine tincture Sublimed sulfur powder Asthma Medications Bronchodilator/expectorant tablets/asthma inhalers Cold, Flu and Allergy Medications Allergy medications Cold relief, cough relief or flu relief (liquid, tablets or drops) Homeopathic sinus medications Medicated chest rub Nasal decongestant (drops, inhaler, spray or strips) Sinus medications, sinus and allergy nasal spray Vapor patch cough suppressant Ear/Eye Care Airplane ear protection Ear drops for swimmers Ear water-drying aid Ear wax removal drops Homeopathic earache tablets Health Aids Anti-fungal treatments Diuretics and water pills Hemorrhoid relief Lice control Medicated bandages Motion sickness tablets Respiratory stimulant ammonia Sleeping aids
•
•
•
Pain Relief Arthritis pain reliever Bunion and blister treatments Itch relief Orajel Pain reliever, aspirin, non-aspirin Throat pain medications Skin Care Acne medications Anti-itch lotion Cold sore/fever blister medications Corn and callus removal medications Diaper rash ointment Eczema cream Medicated bath products Wart removal medications Stomach Care Acid reducers Antacid gum Antacid liquid Antacid tablets Anti-diarrhea medications Gas prevention (liquid, tablets or drops) Ipecac syrup Laxatives Pinworm treatment Prilosec Upset stomach medications
Over-the-Counter Expenses That Do Not Qualify for Reimbursement • • • • • • • • •
Aromatherapy Baby bottles and cups Baby oil Baby wipes Blistex/Chapstick Breast enhancement system Cosmetics Cotton swabs Dental floss
• • • • • • • • •
Deodorants Facial care Feminine care fragrances or facial care products Feminine hygiene products Hair regrowth Insoles Low calorie foods Low “carb” foods
• • • • • • •
Mouthwash/oral care/toothbrushes Petroleum jelly Shampoo and conditioner Skin care Spa salts Sun clips Sun tanning products
Over-the-Counter Expenses That Do Not Require a Physician’s Prescription • • • • •
• • •
Bandages, gauze and related items Blood pressure monitors Cholesterol test kits and supplies Colorectal cancer screening tests Condoms and other OTC contraceptives Contact lens cleaning solutions Crutches, canes, walkers and wheelchairs Denture adhesives 30
• • • • • • • • •
Diabetic supplies, including Insulin Fertility monitors First aid kits Hearing aids and batteries Heat wraps and cold packs Home drug tests Hydrogen peroxide Incontinence supplies (Depends, Serenity pads) Latex gloves
• • • • •
• •
Occlusal guards (for teeth grinding) Oral syringes Ovulation predictor kits Pregnancy test kits Reading glasses and other OTC eyeglasses Rubbing alcohol Thermometers
FSA (Flexible Spending Account) FSAStore for Eligible Products The thousands of products that are available at FSAStore are all FSA/HSA eligible or FSA/HSA eligible with a prescription and can be purchased with your FSA/HAS debit card or any major credit card. FSAStore offers free shipping on orders of at least $50, and its prices on brand name products are very competitive. When you take into account that you are using pre-tax dollars, you generally save up to 40%. Visit FSAStore by logging into www.mywealthcareonline.com/higginbotham and clicking on the banner.
FSAStore is the one-stop destination for Flexible Spending Accounts
FSAStore helps make purchasing FSA/HAS eligible products, finding local FSA eligible services and answering the many questions about Flexible Spending Accounts simple. FSAStore makes spending your FSA funds easy.
ONE-STOP SHOPPING FOR ALL YOUR OTC NEEDS!
The FSAStore services channel allows you to search for nearby eligible services, such as acupuncture and chiropractic care. You can browse through a database of more than 300,000 health care providers by zip code. FSAStore offers instant access to common questions and answers about FSAs/HSAs via the learning center and is focused on keeping you informed about ongoing changes to FSA/HSA benefits. FSAStore ACCEPTS OVER-THE-COUNTER PRESCRIPTIONS! You can easily shop for FSA eligible prescription products using your FSA/HSA debit card. You can choose to have your physician submit prescriptions to FSAStore, have FSAStore call your physician to obtain the prescription, or you may mail the prescription directly to FSAStore to enjoy the tax-free benefit of over-the-counter products that require a prescription in order to be reimbursed.
31
FSA (Flexible Spending Account) Health Care Spending Account Worksheet Accurate budgeting of out-of-pocket medical expenses not reimbursed or covered by insurance is necessary to gain maximum benefit from the Health Care Spending Account. Only expenses that you know you or your family will incur during the plan year can be included in the program. You should consider your cost of deductibles and coinsurance features of any medical and dental insurance policies as well as those costs not covered by insurance. INCLUDE EXPENSES FOR ALL MEMBERS OF YOUR IMMEDIATE FAMILY!!
PLANNED MEDICAL EXPENSES Known Annual Medical Expenses (those expenses not covered by insurance that your entire family will incur during the plan year for the following services): Deductibles — Coinsurance
Prescriptions and Doctor Visits (CO-PAYS) Over-the-Counter Medications (with RX) Massage Therapy (Dr.’s RX Needed) Lasik Eye Surgery
Medical Supplies and Equipment Therapist, Psychologist, Chiropractor Hearing Aids and Supplies Laboratory and X-ray Expenses
PLANNED DENTAL CARE (Your portion of these expenses) Deductibles Fillings and Crowns Extractions, Dentures and Bridgework
Oral Surgery Orthodontic Expenses
PLANNED VISION CARE Examination
Glasses/RX Sunglasses Contact Lenses, Solution and Materials
TOTAL
$
Total Expenses / # of pay periods =
$
This is only a worksheet and is just for your use. Visit our website at www.mywealthcareonline.com/higginbotham for more information.
32
FSA (Flexible Spending Account) Reasons to Take Advantage of the Tax Savings Now Taking advantage of the Health FSA and Dependent Care FSA doesn’t change what you do at tax time. You actually get a “tax refund” on every paycheck after electing the benefits because you pay no tax on the money you set aside each pay period. You decide how much money to put into the plan and where and when to spend the money in your account. This is a great way to budget. A regular amount is deducted from your paycheck, but the entire annual election is always available for you to spend on eligible expenses from day one of the plan year. Once you have enrolled in the plan, everything you need can be found at the website www.mywealthcareonline.com/ higginbotham. You can even enter your claim online. Then you just print the claim form and submit it along with your detailed receipts. It only takes a few moments to go to the website and familiarize yourself with the reimbursement plan. Turning in a reimbursement claim is quick and easy. Don’t worry about it making your social security benefits smaller because social security benefits are based on your lifetime earnings history. Your social security benefits may be slightly reduced by participating in the plan. However, tax advisors will tell you that the tax savings you earn today will far outweigh any reduction in social security benefits. The Flexible Spending Accounts are not just for people who need prescription drugs and have children — everyone has medical expenses, not just families. And with the new IRS Revenue ruling, anyone who buys over-thecounter (OTC) drugs may be reimbursed through the plan. The plan is not just for prescription drugs. Things like cough syrup, pain relievers, allergy medicine, etc. are included with an OTC prescription. It is OK if both you and your spouse enroll in a similar plan at work. There is no IRS limit on the amount of medical expenses that can be reimbursed per household. Each employer sets the annual limits for the Health FSA plan.
Don’t worry that you cannot afford to have any more money taken out of your paycheck… Did you know you can get money out of the plan before you put it in? By joining the plan, you can have the plan pay your health care expenses in full at the time of service, even before you make your contribution. Do you take a deduction for medical expenses on a Form 1040? If so, you can only do so after you spend in excess of 7.5%-10% of your adjusted gross income for them. The first dollar you pay for unreimbursed medical expenses is not deductible on your Form 1040. But through the Health FSA, the very first dollar you spend will earn you 25%-40% in tax savings.
Dependent Care Spending Account • • • • • • • •
• •
You and your spouse must be employed in order to participate, or one of you can be a full-time student actively looking for work, or disabled. Kindergarten is not reimbursable, unless it can be determined that the educational part is incidental and cannot be separated from the cost of care. Overnight camps are not eligible — only day camps can be considered. Household service is eligible if part of the service is for the care of a qualifying person. Before and after school care is eligible. Your care provider cannot be your dependent. The debit card cannot be used for dependent child care. The maximum flex deduction per family per year is $5,000 when filing jointly or head of household; and $2,500 when married filing separately. HOWEVER, the IRS maximum limit for income tax purposes is $6,000 and $3,000 — whatever amount you do not deduct from your Flexible Spending Account, you can deduct the difference (up to $3,000 or $6,000) on your income tax return. Any care for your children whom you claim as tax dependents under the age of 13 is eligible. A person may qualify for only part of the year if he/she turns 13 mid-year. Care for spouse or dependents of any age who spend at least eight hours a day in your home, who are mentally or physically incapable of self-care is eligible.
33
FSA (Flexible Spending Account) Answers to Common Questions
Mobile myRSC
Q: I take a dependent care credit on Form 1040. Will the Dependent Care Spending Account save more? A: The more you earn, the more you’ll save. In addition, you’ll also save social security tax (FICA) with a Dependent Care Spending Account. So, don’t wait until April 15 to take the credit. Now, you can save taxes on every paycheck.
Benefits at Your Fingertips You can access your employee account information on your smartphone with the mobile app for iPhone and Android.
Which is best for you? Visit www.mywealthcareonline.com/ higginbotham and use the easy calculator under the Employees tab to determine your savings. Q: Are there any negatives I should know about? A: Because you will not pay social security tax on the amount of gross pay you set aside to pay for qualified expenses, your social security benefits at retirement may be slightly reduced. However, most tax advisors recommend taking advantage of current taxsavings opportunities like the Health FSA and Dependent Care FSA. Also, if disability insurance is paid on a pre-tax basis, any future benefits you receive will be taxable.
Quick Tips on Submitting Your Claims to Avoid Denial
Locating and Loading the Mobile App Simply search for “Higginbotham” on the App StoreSM for Apple products or on the Google Play™ Store for Android products, and then load as you would any other app.
What You Can Do with the Mobile App • • •
•
View Accounts: Detailed account and balance information. Card Activity: Account information. SnapClaim: File a claim and upload receipt photos directly from your smartphone. Manage Subscriptions: Set up e-mail notifications to keep you up-to-date on all account and health debit card activity.
How to Use the Mobile App
We need to know the date of service in order to pay the claim when you submit a dental or doctor bill. Please DO NOT submit “balance forward” or “previous balance” statements. On your doctor visit co-pays, we need the actual statement from the doctor if the charge is anything other than a co-pay amount. They will print a statement for you. We need date of service, service rendered, patient’s name, insurance payments, etc. If the statement is pink or yellow, please make a dark copy before faxing. The pink and yellow copies are not legible when faxed. An OTC RX Checklist is located at the back of this booklet. Please have your physician complete this form and return it to us, and any over-the-counter items you submit will be reimbursable back to you. When submitting a statement for a coinsurance, deductible or hospital expense, please make sure the Explanation of Benefits (EOB) states very clearly the date of service, patient name and procedure. The best document to submit is the EOB from your health insurance provider, as all these details will be included once insurance has been processed. For any forms, worksheets, or informational flyers referenced in this document, please visit: www.mybenefitshub.com/ fortworthisd
Thank You for Your Help in the Above Submitting a complete claim request helps us pay all eligible claims in full and will also eliminate the letters coming back to 34 you requesting more information regarding the reimbursement!
Logging In Use the same username and password you use to log in to www.mywealthcareonline.com/higginbotham. After logging in, you will be on the home page, which will list your options. Getting Help Click the Help button at the bottom right of all pages to access contact information for your administrator, who will be able to provide assistance. Going Home Press the Home button on the bottom left corner of any page to return to the home page and start over.
FSA (Flexible Spending Account) WealthCare Card The debit card is a quick and easy way to pay for qualified expenses from your Flexible Spending Account. You have no out-of-pocket expense — the money is taken directly out of your account. Plus, you don’t have to wait on reimbursement. Go to www.mywealthcareonline.com/higginbotham and request your Flex debit card. Employee • 24/7 access to plan documents, letters and notices, forms, account balances, contributions, investments and other plan information or cafeteria plans, health reimbursement arrangements and transit plans • Change personal information/census data online • Access to contact information or the administrator • Access to 125 tax calculators
Debit Card Procedure •
• •
• •
•
Use your debit card at the time of service (doctor’s office, hospital, pharmacy, etc.). The debit card cannot be used for child care. Make sure you get a statement for the service rendered. • Hospital: Statement from the doctor with the procedure code and diagnosis code, date of service, name of patient and name and address of the provider. • Dental/Vision: Statement with the procedure code, date of service, name of patient and name and address of the provider. Fax in the statement the next time you come to work: 817-882-9267 or toll-free 866-419-3516. You can either fax the documents after you have received your services OR you can wait until you receive an e-mail from the plan requesting that you send in the statements. You will NOT get an e-mail for all of your swipes — the copays for your doctor visits and prescription co-pays will automatically substantiate. However, any time you swipe the card for any amount other than a copay amount, you will need to submit the itemized statement or an Explanation of Benefits. Very Important: If you do not fax the documentation within 60 days from the date you receive the e-mail, your debit card will be suspended until proper substantiation is received.
Debit Card FAQs Q: Can I use my debit card to pay for over-the-counter drugs? A: No. You must provide a physician-signed over-the-counter prescription, and you must submit a paper claim for these items and then be reimbursed.
Q: The following items are auto substantiated: A: (1) Certain transactions involving dollar amounts that are consistent with predetermined co-pay under the plan. (2) Certain recurring previously approved expenses. (3) Certain charges that are substantiated at the time of the sale or if the vendors that participate are in the inventory information system (IIAS). Q: Purchases at pharmacies and medical providers that do not subscribe to the IIAS are treated as conditionally approved and paid at the time of service; statements must be faxed after the purchase to substantiate the purchase was for a qualified expense, i.e.: A: (1) A dentist office could charge you $200 for teeth bleaching. The $200 would be approved at the time of sale, but the member must submit the statement with the required information. Since teeth bleaching is not a covered expense, the claim would be denied, and the member would pay the plan $200. (2) A physician could charge $150 for a consult for cosmetic surgery. The $150 would be approved at the time of purchase, but cosmetic surgery is not a covered item and the claim is not eligible for reimbursement under IRS guidelines. The claim would be denied, and the member would owe the plan $150. (3) A member pays $125 for a qualified medical expense. He/ she uses the debit card, sends in the form with the required information, and it is marked as eligible in the system.
Renewing Your Debit Card • • •
Your debit card will work for three years initially. Check the expiration date on front of the card. If your company has the “grace extension” added to the end of the plan year and you have a “balance” from the old year, that balance will “transfer” to the new debit card. If your card is “suspended” as of the last day of your "submission" deadline date, you will be taxed on the amount not substantiated. A letter will be sent to your home on the last day of your plan year to let you know that you will need to substantiate these by submission deadline to avoid being taxed on this amount.
New Plan Year Debit Card Use with an Old Plan Year Balance The main thing to keep in mind is that if your company has the “grace extension” or "rollover provision" on the prior plan year, the balance in your “prior” plan year will be loaded to your debit card — the system will automatically do a “look back” at the old plan year and apply these expenses to that plan year first.
35
Fax or mail to:
36
Attn: Flex Department c/o Higginbotham 500 W. 13th Street Fort Worth, TX 76102 Phone: 866-419-3519 Fax: 817-882-9267 Toll-Free Fax: 866-419-3516 E-mail: flexclaims@higginbotham.net
Flex Debit Card Reimbursement
Health Care Spending Account Reimbursement Form Employer Name Employee Name Employee SSN Address
City
Phone
State
Zip
Patient Name and Relationship to Employee Do you have medical insurance?
Yes
No
Do you have dental insurance? (check only if submitting dental expenses)
Yes
No
For most expenses, attach receipts that include date of service, provider, amount of charge and H[SODQDWLRQ RI H[SHQVH &UHGLW GHELW FDUG UHFHLSWV DUH DFFHSWHG IRU WKH FRSD\ DPRXQW RQO\ $OO¢RWKHUV ZLOO UHTXLUH HLWKHU DQ ([SODQDWLRQ RI %HQH´WV (2% RU DQ LWHPL]HG VWDWHPHQW RI FKDUJHV &DVK UHJLVWHU receipts for RXs are not accepted—we need the receipt that is stapled to your RX bag. Amounts covered do not include payments under any other health care plan or program, federal, state or governmental program, workers' compensation or any other policy or health insurance. I certify that the above information is correct to the best of my knowledge and that each item or expense is eligible for reimbursement. I certify that these expenses have not been reimbursed, and I will not seek reimbursement for them under a major plan or any other health plan, such as an individual policy or my spouse's or dependent's health plan. I understand that the expense for which I am reimbursed may not be used to claim any federal income tax deduction or credit. I authorize any physician, hospital or other organization or person having any records, data or information concerning health history or other insurance for me or my dependents to furnish such records, data or information as may be requested by Higginbotham.
Date
Employee Signature
Fax or mail to:
Attn. Flex Department c/o Higginbotham 500 W. 13th Street Fort Worth, TX 76102 Phone: 866-419-3519 Fax: 817-882-9267 Toll-Free Fax: 866-419-3516 (PDLO µH[FODLPV#KLJJLQERWKDP QHW
37
Dependent Care Spending Account Reimbursement Form Employer Name Employee Name Employee SSN Address
City
Phone
State
Zip
Child(ren) Name(s) Date(s) of Service
Charge(s)
Name and Address of Facility or Provider
Provider's Tax ID or SSN Signature of Provider
The dependent care expenses hereby presented for reimbursement from the plan have not been reimbursed and will not be reimbursed through any other dependent care plan, including other dependent FDUH ÂľH[LEOH VSHQGLQJ DUUDQJHPHQWV
Employee Signature
Fax or mail to:
38
Date
Attn. Flex Department c/o Higginbotham 500 W. 13th Street Fort Worth, TX 76102 Phone: 866-419-3519 Fax: 817-882-9267 Toll-Free Fax: 866-419-3516 (PDLO ÂľH[FODLPV#KLJJLQERWKDP QHW
Authorization for Direct Deposit Section 125 Reimbursement Account
Employer Name Employee Name Employee SSN
I hereby authorize Higginbotham to initiate credit or debit entries to my checking account or savings account indicated below.
Check only one:
Checking Account
Savings Account
Bank ACH Transit Routing Number Account Number
7KLV DXWKRULW\ ZLOO UHPDLQ LQ IXOO IRUFH DQG HIIHFW XQWLO +LJJLQERWKDP KDV UHFHLYHG ZULWWHQ QRWL´FDWLRQ IURP me of its termination in such time and in such manner as to afford Higginbotham a reasonable opportunity to act on it.
Date
Employee Signature
AN ACTUAL VOIDED CHECK MUST BE ATTACHED If an actual check is not available to attach, you are responsible for obtaining the correct ACH transit URXWLQJ QXPEHU IURP \RXU ´QDQFLDO LQVWLWXWLRQ
Do not submit deposit slip information, as it will not be accepted.
Fax or mail to:
Attn. Flex Department c/o Higginbotham 500 W. 13th Street Fort Worth, TX 76102 Phone: 866-419-3519 Fax: 817-882-9267 Toll-Free Fax: 866-419-3516 (PDLO µH[FODLPV#KLJJLQERWKDP QHW
39
UNITED CONCORDIA
Dental Indemnity
YOUR BENEFITS PACKAGE
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.
Roughly 78% of Americans have had at least one cavity by age 17. 80% of the U.S. population has some form of periodontal disease.
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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 40 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Dental Indemnity Monthly Premiums Tier
Rate
EE Only
$41.35
EE + Spouse
$83.22
EE + Child(ren)
$92.34
Family Coverage
$134.02
Dental Benefits Summary for Fort Worth Independent School District Group Numbers: 821479-000/001/002/003 Network: Elite Plus www.UnitedConcordia.com | 1-800-332-0366
Benefit Category1
CONCORDIA FLEX PLAN In-Network2 Non-Network2
Class I - Diagnostic/Preventive Services Exams Bitewing X-rays All Other X-rays Cleanings & Fluoride Treatments Sealants Palliative Treatment Nonsurgical Periodontics
100%
100%
80%
80%
50%
50%
50%
50%
Class II - Basic Services Basic Restorative (Fillings) Simple Extractions Space Maintainers Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Endodontics Surgical Periodontics Complex Oral Surgery
Class III - Major Services Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures)
Orthodontics for dependent children to age 19 Diagnostic, Active, Retention Treatment
Included Plan Features Pregnancy Benefit
• Covers 1 additional cleaning during pregnancy • Covers 1 additional periodontal maintenance during pregnancy • Scaling and root planing • 4 periodontal surgery procedures
Maximums & Deductibles (applies to the combination of services received from network and non-network dentists) Annual Program Deductible (per person/per family) Annual Program Maximum (per person) Lifetime Orthodontic Maximum (per person)
$50/$150 (Excludes Class I & Orthodontics) $1,500 (Excludes Orthodontics) $1,500
Waiting Periods3 (Applicable to new Entrants) Class I Class II Class III Orthodontics for dependents to age 19
None None 6 months 6 months
None None 6 months 6 months
Reimbursement
Elite Plus
90th
Representative listing of covered services – certificate of coverage provides a detailed description of benefits. 1. Unmarried dependent children covered to age 26. 2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances a s payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply. 3. Waiting Periods are applicable to new Entrants 41 4. Calendar year is January 1, XXXX - December 31, XXXX.
HUMANA
Dental
YOUR BENEFITS PACKAGE
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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 42 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
DHMO 150 C Plan with Ortho Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental C Series dental plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect with HumanaDental. • No waiting periods • No claims to file • No annual maximums
Know what your plan covers Attached is a summary of HumanaDental C Series plan benefits which are described in detail in your certificate. You can find your certificate at www.HumanaDental.com or call 1-800-9794760. Here’s what you can expect:
•
•
•
•
You have the freedom to select any participating dentist. To select a dental provider from our network, simply visit www.HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-979-4760. Life without claim forms! With HumanaDental DHMO plan you pay your dentist directly, when applicable. Your primary dentist will provide all of your routine dental care and any copayment or discounted charges will be paid at the time of service. Copayments are applicable at either a participating general dentist or a participating specialist. If you need a specialty dentist, you may receive a 25 percent discount by using certain participating specialty dentists from our network. Visit www.HumanaDental.com to find a participating specialist who offers the discount on specialty services.
Questions? Check out www.HumanaDental.com Call 1-800-979-4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist.
Check your dental IQ anytime Log on to www.MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at www.MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.
Monthly DHMO Premiums Tier
Rate
EE Only
$12.66
EE + Spouse
$22.60
EE + Child(ren)
$23.96
Family Coverage
$31.18
Dependent Max Age Limit: to Age 26
Choose HumanaDental benefits Be healthy Good oral health means more than just an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so.
43
DHMO 150 C Plan with Ortho The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. C plans copayments are applicable at either a participating general dentist or a participating specialist. Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your dental professional, your PCD may decide that you need to see an contracted dental specialist. No referral is necessary to see a network specialist. Specialists services: Should you need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), you may be referred by your participating general dentist, or you may refer yourself to any participating specialist. For C plans and benefits for procedures not listed on the schedule, you may receive a 25 percent discount by visiting certain participating specialists. Visit www.HumanaDental.com to find a participating specialist who offers the discount on specialty services.
Summary of services Appointments D9310
Consultation (diagnostic service provided by dentist other than practitioner providing treatment)
Member Pays $ 15.00
Preventive (cont.)
Member Pays
D1351
Sealant-per tooth
$ 10.00
D1510
Space maintainer—fixed, unilateral
$ 45.00+labΔ
Space maintainer—fixed, bilateral
$ 45.00+labΔ
D9430
Office visit (normal hours)
$ 5.00
D1515
D9440
Office visit (after regularly scheduled hours)
$ 35.00
D1520
Space maintainer—removable, unilateral
$ 85.00+labΔ
Member Pays
D1525
Space maintainer—removable, bilateral
$ 85.00+labΔ
D1550
Recementation of space maintainer
Diagnostic D0120
Periodic oral examination
no charge
D0140
Limited/comprehensive/detailed and extensive oral eval
no charge
Restorative
D0150
Limited/comprehensive/detailed and extensive oral eval
no charge
D2140
Amalgam—one surface, primary or permanent
no charge
D0160
Limited/comprehensive/detailed and extensive oral eval
no charge
D2150
Amalgam—two surfaces, primary or permanent
no charge
D0180
Comprehensive periodontal evaluation
D0210
X-ray intraoral—complete series including bitewings
no charge
D2160
Amalgam—three surfaces, primary or permanent
no charge
D0220
X-ray intraoral—periapical, first film
no charge
D2161
Amalgam—four or more surfaces, primary or permanent
no charge
D0230
X-ray intraoral—periapical, each additional film
no charge
D2940
Sedative filling
D0270
X-ray bitewing—single film
no charge
D2999
Sedative base (under fillings), by report
D0272
X-ray bitewings—two films
no charge
Resin Restorative
D0274
Bitewings—four films
no charge
D2330
Resin based composite—one surface, anterior
$ 35.00
D0330
Panoramic film
no charge
D0460
Pulp vitality tests
no charge
D2331
Resin based composite—two surfaces, anterior
$ 40.00
D0470
Diagnostic casts
no charge
D2332
Resin based composite—three surfaces, anterior
$ 50.00
Preventive
$ 10.00
Member Pays
$ 10.00
Member Pays
$ 15.00 no charge
Member Pays
D1110
Prophylaxis—adult, routine (once every 6 months)
no charge
D2391
Resin based composite—one surface, posterior
$ 60.00
D1120
Prophylaxis—child, routine (once every 6 months)
no charge
D2392
Resin based composite—two surfaces, posterior
$ 80.00
D1110
Prophylaxis—adult/child, (additional)
$ 20.00
D2393
Prophylaxis—adult/child, (additional)
$ 20.00
Resin based composite—three surfaces, posterior
$ 100.00
D1120
Topical application of fluoride (not including prophylaxis)—child (up to 16 years of age)
D2394 no charge
Resin based composite—four or more surfaces, posterior
$ 120.00
D1203
D2510
Inlay—metallic, one surface
$ 95.00
D1206
Topical fluoride varnish (for child <16)
no charge
D2520
Inlay—metallic, two surfaces
$ 105.00
Oral hygiene instruction
no charge
D2530
Inlay—metallic, three or more surfaces
$ 130.00
D1330
44
DHMO 150 C Plan with Ortho Crown and Bridge
Member Pays
D2740
$ 280.00+labΔ
Crown—porcelain/ceramic substrate
fused to high noble D2750* Crown—porcelain metal
$ 280.00
Crown—porcelain fused to predominantly base metal
$ 280.00
D2751
D2752* Crown—porcelain fused to noble metal
$ 280.00
D2790* Crown—full cast high noble metal
$ 280.00
D2791
Crown—full cast predominantly base metal
$ 280.00
D2792* Crown—full cast noble metal
$ 280.00
D2910
Recement inlay
$ 15.00
D2920
Recement crown
$ 15.00
D2930
Prefabricated stainless steel crown— primary tooth
$ 75.00
D2950
Core buildup, including any pins
$ 45.00
D2951
Pin retention—per tooth, in addition to restoration
$ 15.00
D2952
Cast post and core in addition to crown
$ 90.00+labΔ
D2953
Each additional cast post—same tooth
$ 90.00+labΔ
D2954
Prefabricated post and core in addition to crown
$ 90.00
D2962
Labial veneer (porcelain laminate)— laboratory
$ 280.00+labΔ
Prosthodontics (Fixed)
Member Pays
D6210* Pontic—cast high noble metal
$ 280.00
D6211
$ 280.00
Pontic—cast predominantly base metal
Endodontics (cont.)
Member Pays
D3330
Root canal therapy—molar (excluding final restoration)
$ 250.00
D3410
Apicoectomy/periradicular surgery— anterior
$ 125.00
Periodontics (Gum Treatment)
Member Pays
D4210
Gingivectomy/gingivoplasty per quadrant
$ 125.00
D4211
Gingivectomy/gingivoplasty per tooth
$ 40.00
D4341
Periodontal scaling and root planing, per quadrant
$ 50.00
D4342
Periodontal scaling and root planing 1 to 3 teeth per quadrant
$ 50.00
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis
$ 45.00
D4381
Localized delivery of chemotherapeutic agents (per tooth)
$ 45.00
D4910
Periodontal maintenance
$ 50.00
Prosthodontics
Member Pays
D5110
Complete denture—maxillary
$ 300.00+labΔ
D5120
Complete denture—mandibular
$ 300.00+labΔ
D5130
Immediate denture—maxillary
$ 300.00+labΔ
D5140
Immediate denture—mandibular
$ 300.00+labΔ
D5211^ Maxillary partial denture—resin base
$ 300.00+labΔ
D5212^ Mandibular partial denture—resin base
$ 300.00+labΔ
D5213^ Maxillary partial denture—cast metal framework, resin denture bases
$ 300.00+labΔ $ 300.00+labΔ
D6212* Pontic—cast noble metal
$ 280.00
fused to high noble D6240* Pontic—porcelain metal
$ 280.00
Mandibular partial denture—cast D5214^ metal framework, resin denture bases
Pontic—porcelain fused to predominantly base metal
$ 280.00
D5410
Adjust complete denture—maxillary
$ 15.00
$ 280.00
D5411
Adjust complete denture—mandibular
$ 15.00
D5421
Adjust partial denture—maxillary
$ 15.00
D5422
Adjust partial denture—mandibular
$ 15.00
D6241
D6242* Pontic—porcelain fused to noble metal
fused to high noble D6750* Crown—porcelain metal
$ 280.00
Crown—porcelain fused to predominantly base metal
$ 280.00
D6751
Repairs to Prosthetics
Member Pays
D5510
Repair broken complete denture base
$ 15.00+labΔ
D6752* Crown—porcelain fused to noble metal
$ 280.00
D6790* Crown—full cast high noble metal
$ 280.00
D5520
Replace missing or broken teeth— complete denture (each tooth)
$ 15.00+labΔ
$ 280.00
D5610
Repair resin denture base
$ 15.00+labΔ
$ 280.00
D5630
Repair or replace broken clasp
$ 15.00+labΔ
D5640
Replace broken teeth—per tooth
$ 15.00+labΔ
D5650
Add tooth to existing partial denture
$ 30.00+labΔ
D5730
Reline complete maxillary denture (chairside)
$ 50.00
D6791
Crown—full cast predominantly base metal
D6792* Crown—full cast noble metal D6930
Recement fixed partial denture (per unit)
Endodontics
$ 10.00
Member Pays
D3220
Therapeutic pulpotomy
$ 35.00
D3221
Pulpal debridement, primary and permanent teeth
$ 100.00
D5731
Reline complete mandibular denture (chairside)
$ 50.00
D3310
Root canal therapy—anterior (excluding final restoration)
$ 100.00
D5740
Reline maxillary partial denture (chairside)
$ 50.00
D3320
Root canal therapy—bicuspid (excluding final restoration)
$ 200.00
D5741
Reline mandibular partial denture (chairside)
$ 50.00 45
DHMO 150 C Plan with Ortho Repairs to Prosthetics (cont.)
Member Pays
D5750
Reline complete maxillary denture (laboratory)
$ 35.00+labΔ
D5751
Reline complete mandibular denture (laboratory)
$ 35.00+labΔ
D5760
Reline maxillary partial denture (laboratory)
$ 35.00+labΔ
D5761
Reline mandibular partial denture (laboratory)
D5850
Tissue conditioning—maxillary
$ 30.00
D5851
Tissue conditioning—mandibular
$ 30.00
Extractions/Oral & Maxillofacial Surgery
$ 35.00+labΔ
Coronal remnants, deciduous tooth
no charge
D7140
Extraction, erupted tooth or exposed tooth
no charge
D7210
Surgical removal of erupted tooth
$ 40.00
D7220
Removal of impacted tooth—soft tissue
$ 50.00
D7230
Removal of impacted tooth—partially bony
$ 70.00
D7240
Removal of impacted tooth— completely bony
$ 85.00
D7250
Surgical removal of residual tooth roots
$ 35.00
D7310
Alveoloplasty in conjunction with extractions—per quadrant
$ 35.00
D7311
Alveoplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant
$ 35.00
D7320
Alveoloplasty not in conjunction with extractions—per quadrant
$ 70.00
D7321
Alveoplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant
$ 70.00
D7510
Incision and drainage of abscess— intraoral
$ 25.00
D9215
Local anesthesia
D9230
Analgesia (nitrous oxide), per 15 minutes
Palliative (emergency) treatment
$ 25.00
D9450
Case presentation, detailed and extensive treatment planning
no charge
D9951
Occlusal adjustment—limited
D9952
Occlusal adjustment—complete
Orthodontics
D8070
Consultation
Records/treatment planning
$ 250.00
$ 35.00
Records/treatment planning
$ 250.00 $ 2,300.00
Comprehensive orthodontic treatment of the adult dentition; Adult 19 years of age and over; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
Records/treatment planning Orthodontic treatment D8680
no charge
Evaluation
Evaluation
no charge
$ 2,300.00
Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
Consultation
Member Pays
no charge $ 35.00
Consultation
D8090
$ 150.00
Member Pays
Evaluation Orthodontic treatment
D8080
$ 25.00
Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
Orthodontic treatment
$ 15.00
Member Pays
D9110
Member Pays
D7111
Anesthesia
Adjunctive General Services
Retention
no charge $ 35.00
$ 250.00 $ 2,500.00 $ 450.00
*The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal. The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal. Δ Patient responsible for lab fees. ^ Including any conventional clasps, rests, and teeth. Note: • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted procedures are available at certain participating dentists usual fee less 25%. Visit www.HumanaDental.com to find a participating dentist who offers the discount on non-covered services. • When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional $50 per unit. • If you break your appointment with your dentist without 24-hour advance notice, you will be subject to your dentist’s broken appointment fee. • Additional exclusions and limitations are listed along with full plan information in your certificate of benefits. 46administered by DentiCare, Inc. (d/b/a CompBenefits) Insured or
Advantage Plus 1S Plan Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental Advantage Plus S plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect. • No deductibles • No claims to file • No need to choose a primary care dentist
Know what your plan covers Attached is a summary of HumanaDental Advantage Plus S plan benefits which are described in detail in your certificate. You can find your certificate at www.HumanaDental.com or call 1-800979-4760. Here’s what you can expect:
•
• •
•
You have the freedom to select any participating dentist. To select a dental provider from our Advantage Plus network, simply visit www.HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-9794760. Life without claim forms! With HumanaDental Advantage Plus S plan you pay your dentist directly, when applicable. Your Advantage Plus network dentist will provide all of your dental care and any copayment or discounted charges will be paid at the time of service. Except for emergency care, treatment received out-of-network in not covered. You also receive a 20 percent discount on services not listed on your schedule of benefits when visiting certain participating dentists. Visit www.HumanaDental.com to find a participating dentist who offers the discount on unlisted services.
Questions? Check out www.HumanaDental.com Call 1-800-979-4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist.
Check your dental IQ anytime Log on to www.MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at www.MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.
Monthly DHMO Premiums Tier
Rate
EE Only
$18.70
EE + Spouse
$38.26
EE + Child(ren)
$38.88
Family Coverage
$63.90
Dependent Max Age Limit: to Age 26
Choose HumanaDental benefits Be healthy Good oral health means more than just an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so.
47
Advantage Plus 1S Plan Advantage Plus plans are network-based dental plans that emphasize prevention and cost containment. Members select any participating general dentist in HumanaDental’s Advantage Plus network. Care received from an out-of-network dentist (except emergency care) is not a covered benefit. S plan copayments for listed procedures are applicable only at participating General Dentist. To find a dentist, call 1-800-979-4760 or look on www.HumanaDental.com. Office visit copay $5/$15 Annual maximum No annual maximum
Summary of services Preventive
Member Pays
Basic
Periodic oral examination
no charge
D1510
Space maintainer—fixed, unilateral (limited to child <14)
$53.00
D0140
Limited oral evaluation—problem focused
no charge
D1515
$70.00
D0145
Oral evaluation for a patient under three years of age and counseling with primary caregiver (limit 1 every 12 months)
Space maintainer—fixed, bilateral (limited to child <14)
no charge
D1520
Space maintainer—fixed, bilateral (limited to child <14)
$66.00
D0150
Comprehensive oral evaluation—new/ established patient (limit 1 every 24 months)
no charge
D1525
Space maintainer—removable, bilateral (limited to child <14)
$91.00
D1550
Recementation of space maintainer
$12.00
D0160
Limited/comprehensive/detailed and extensive oral eval (limit 1 every 12 months)
no charge
D2140
Amalgam—one surface primary or permanent
$24.00
D0170
Re-evaluation—limited problem focused (limit 1 every 12 months)
no charge
D2150
Amalgam—two surfaces primary or permanent**
$31.00
D0180
Comprehensive periodontal eval—new/ established patient (limit 1 every 24 months)
no charge
D2160
Amalgam—three surfaces primary or permanent*
$37.00
D2161
no charge
Amalgam—four/more surfaces primary/ permanent**
$46.00
D0210
X-ray intraoral—complete series (limit 1 every 3 years) X-ray intraoral—periapical, first film (limit 9 every 12 months includes D0230)
D2330 no charge
Resin based composite—one surface, anterior**
$24.00
D0220
D2331
Resin based composite—two surfaces, anterior**
$31.00
D0230
X-ray intraoral—periapical, each additional film (limit 9 every 12 months includes D0220)
no charge
D2332
Resin based composite—three surfaces, anterior**
$38.00
D0240
X-ray intraoral—occlusal film
no charge
D0250
X-ray extraoral, first film
no charge
D2335
Resin based composite —four or more surfaces, involving incisal angle**
$45.00
D0260
X-ray extraoral, each additional film
no charge
D2390
$49.00
Bitewing—single film
no charge
Resin based composite—crown anterior**
D0272aΔ Bitewings—two films
no charge
D2391
Resin based composite—one surface, posterior**
$28.00
D0273aΔ Bitewings—three films
no charge
D2392
Resin based composite—two surfaces, posterior**
$37.00
D2393
Resin based composite—three surfaces, posterior**
$46.00
D2394
Resin based composite—four or more surfaces, posterior**
$56.00
D4341
Periodontal scaling and root planing— per quadrant, four or more teeth (limit 1 per quad every 12 months)
$39.00
D4342
Periodontal scaling and root planing— per quadrant, 1-3 teeth (limit 1 per quad every 12 months)
$21.00
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis (limit 1 every 5 years)
$26.00
aΔ a
D0120
aΔ
D0270
aΔ
D0274
Bitewings—four films
no charge
D0277aΔ Vertical bitewings—7 to 8 films
no charge
D0330
Panoramic film (limit 1 every 3 years)
no charge
D0470
Diagnostic casts
no charge
D1110aΔ Prophylaxis—adult (inclusive of D4910) aΔ
D1120
Prophylaxis—child (inclusive of D4910)
D1203aΔ Topical application of fluoride—child (for child <16) aΔ
no charge no charge
no charge
D1206
Topical fluoride varnish (for child <16)
no charge
D1351
Sealant—per tooth (limit 1 per tooth every 12 months for child <14)
no charge
48
Member Pays
Advantage Plus 1S Plan Basic (cont.)
Member Pays
D4910
Periodontal maintenance (limit 1 every 6 months, inclusive of D1110 and D1120)
$23.00
D7111
Extraction coronal remnants deciduous tooth
D7140
Extraction erupted tooth or exposed root
Major
Major (cont.)
Member Pays
D2930
Crown—prefabricated stainless steel, primary tooth
$115.00
$20.00
D2931
Crown—prefabricated stainless steel, permanent tooth
$131.00
$26.00
D2932
Crown—prefabricated resin
$142.00
D2940
Sedative filling
$44.00
D2950
Core buildup including any pins
$110.00
D2951
Pin retention—per tooth addition restoration
$23.00
Member Pays
D2510b
Inlay—metallic, one surface
$313.00
D2520b
Inlay—metallic, two surfaces
$355.00
D2530b
Inlay—metallic, three or more surfaces
$410.00
D2952
Cast post and core in addition to crown
$168.00
b
Onlay—metallic, two surfaces
$402.00
D2954
D2543
Onlay—metallic, three surfaces
$420.00
Prefabricated post and core in addition to crown
$139.00
b
D2544b
Onlay—metallic, four or more surfaces
$437.00
D3220
Therapeutic pulpotomy
$75.00
D2610b
Inlay—porcelain/ceramic, one surface
$368.00
D3310
Root canal therapy—anterior
$315.00
D2620
Inlay—porcelain/ceramic, two surfaces
$389.00
D3320
Root canal therapy—bicuspid
$385.00
Root canal therapy—molar
$497.00
D2630b
Inlay—porcelain/ceramic, three or more surfaces
D3330
$414.00
D3346
Previous root canal therapy—anterior
$424.00
Onlay—porcelain/ceramic, two surfaces
$403.00
D3347
Previous root canal therapy—bicuspid
$500.00
D3348
Previous root canal therapy—molar
$601.00
D3410
Apicoectomy/periradicular surgery— anterior
$361.00
D3421
Apicoectomy/periradicular surgery— anterior
$394.00
D3425
Apicoectomy/periradicular surgery— anterior
$445.00
D3426
Apicoectomy/periradicular surgery— each addtl root
$148.00
D3430
Retrograde filling—per root
$109.00 $358.00
D2542
b
b
D2642
Onlay—porcelain/ceramic, three surfaces
$434.00
b
D2644
Onlay—porcelain/ceramic, four or more surfaces
$461.00
D2650b
Inlay—resin based composite, one surface
$242.00
b
Inlay—resin based composite, two surfaces
$288.00
b
D2652
Inlay—resin based composite, three or more surfaces
$303.00
D2662b
Onlay—resin based composite, two surfaces
$263.00
D4210
Gingivectomy/gingivoplasty—four or more teeth, quad
D2663b
Onlay—resin based composite, three surfaces
$310.00
D4211c
Gingivectomy/gingivoplasty—1 to 3 teeth, quad
$153.00
D2664b
Onlay—resin based ccomposite, four or more surfaces
$332.00
D4240c
D2710
Crown—resin based composite, indirect
$187.00
Gingival flap proc—four or more teeth, quad
$421.00
b
D2720b
D4241c
Gingival flap proc—1 to 3 teeth, quad
$217.00
Crown—resin with high noble metal
$461.00
Clinical crown lengthening—hard tissue
$481.00
Crown—resin with predominantly base metal
D4249
D2721b
$432.00
D4260
$680.00
D2722
Crown—resin with noble metal
$441.00
Osseous surgery—four or more teeth, quad
D2740b
D4261
Crown—porcelain/ceramic substrate
$473.00
D2643b
D2651
b
c
Osseous surgery—1 to 3 teeth, quad
$354.00
c
Complete denture—maxillary
$642.00
c
D5120
Complete denture—mandibular
$642.00
D5130c
Immediate denture—maxillary
$700.00
D5110
Crown—porcelain fused to high noble metal
$466.00
D2751b
Crown—porcelain fused predom base metal
$434.00
D5140
Immediate denture—mandibular
$700.00
D2752b
Crown—porcelain fused to noble metal
$445.00
D5211d
Maxillary partial denture—resin base
$542.00
b
Crown—full cast high noble metal
$450.00
D5212d
Mandibular partial denture—resin base
$629.00
b
D2791
Crown—full cast predom base metal
$426.00
D2792b
Crown—full cast noble metal
$434.00
D5213d
Maxillary partial denture—cast metal— resin base
$709.00
D2910
Recement inlay, onlay or part coverage restoration
$41.00
D5214d
Mandibular partial denture—cast metal— resin base
$709.00
D2920
Recement crown
$42.00
D5410c
Adjust complete denture—maxillary
$35.00
b
D2750
D2790
d
49
Advantage Plus 1S Plan Major (cont.)
Member Pays
D5411c
Adjust complete denture—mandibular
$35.00
D5421c
Adjust partial denture—maxillary
$35.00
D5422c
Adjust partial denture—mandibular
D5510
Major (cont.)
Member Pays
D6603
Inlay—cast high noble metal, three or more surfaces
$418.00
$35.00
D6604f
Inlay—cast predom base metal, two surfaces
$372.00
Repair broken complete denture base
$70.00
D6605f
$59.00
Inlay—cast predom base metal, three or more surfaces
$394.00
D5520
Replace missing/broken teeth— complete denture
f
Inlay—cast noble metal, two surfaces
$366.00
D5610
Repair resin denture base
$76.00
f
D5620
Repair cast framework
$82.00
D6607
Inlay—cast noble metal, three or more surfaces
$406.00
D5630
Repair or replace broken clasp
$100.00
D6608f
Onlay—porcelain/ceramic, two surfaces
$386.00
D6609
Onlay—porcelain/ceramic, three or more surfaces
$403.00
D6610f
Onlay—cast high noble metal, two surfaces
$409.00
D6611f
Onlay—cast high noble metal, three or more surfaces
$448.00
D6612f
Onlay—cast predom base metal, two surfaces
$407.00
D6613f
Onlay—cast predom base metal, three or more surfaces
$426.00
D6614f
Onlay—cast noble metal, two surfaces
$399.00
D6615f
Onlay—cast noble metal, three or more surfaces
$414.00
f
Crown—resin with high noble metal
$474.00
f
D6606
f
D5640
Replace broken teeth—per tooth
$64.00
D5650
Add tooth to existing partial denture
$88.00
D5660
Add clasp to existing partial denture
$105.00
D5710e
Rebase complete maxillary denture
$261.00
D5711
Rebase complete mandibular denture
$249.00
D5720e
Rebase maxillary partial denture
$246.00
e
Rebase mandibular partial denture
$246.00
e
D5730
Reline complete maxillary denture
$147.00
D5731e
Reline complete mandibular denture
$147.00
D5740e
Reline maxillary partial denture
$135.00
D5741
Reline mandibular partial denture
$135.00
D6720
D5750e
Reline complete maxillary denture
$196.00
f
D6721
Crown—resin with predom base metal
$450.00
D5751e
Reline complete mandibular denture
$196.00
D6722f
Crown—resin with noble metal
$458.00
D5760
Reline maxillary partial denture
$193.00
f
D6740
Crown—porcelain/ceramic
$499.00
D5761e
Reline mandibular partial denture
$193.00
D6750f
Tissue conditioning maxillary
$61.00
Crown—porcelain fused to high noble metal
$486.00
D5850 D5851
Tissue conditioning mandibular
$61.00
D6751f
Crown—porcelain fused to predom base metal
$453.00
D6092
Recement implant/abutment supported crown
$42.00
D6752f
Recement implant/abutment supported fixed partial denture
$57.00
e
D5721
e
e
D6093 f
Crown—porcelain fused to noble metal
$464.00
f
D6780
Crown—3/4 cast high noble metal
$458.00
D6790f
Crown—full cast high noble metal
$469.00
f
D6210
Pontic—cast high noble metal
$431.00
D6791
Crown—full cast predom base metal
$445.00
D6211f
Pontic—cast predominantly base metal
$404.00
f
D6792
Crown—full cast noble metal
$461.00
D6212f
Pontic—cast noble metal
$420.00
f
D6930
Recement fixed partial denture
$57.00
f
D6240
Pontic—porcelain fused to high noble metal
$426.00
f
D6970
Cast post & core addl fix part denture retainer
$157.00
D6241f
Pontic—porcelain fused predom base metal
$393.00
D6972f
Prefab post & core addl fix part denture retainer
$128.00
f
Pontic—porcelain fused to noble metal
$415.00
f
D6250
Pontic—resin with high noble metal
$420.00
D6973f
Core build up for retainer including any pins
$103.00
D6251f
Pontic—resin with predominantly base metal
$388.00
D7210
Surgical removal—erupted tooth
$108.00
D6252f
D7220
Removal of impacted tooth—soft tissue
$135.00
Pontic—resin with noble metal
$400.00
D6600f
Inlay—porcelain/ceramic, two surfaces
$355.00
D7230
Removal of impacted tooth—partially bony
$179.00
D6601f
Inlay—porcelain/ceramic, three or more surfaces
$373.00
D7240
Removal of impacted tooth—completely bony
$211.00
D6602f
Inlay—cast high noble metal, two surfaces
$380.00
D7241
Remove impacted tooth—completely bony w/comp
$165.00
D6242
50
Advantage Plus 1S Plan Major (cont.)
Member Pays
D7250
Surgical removal of residual tooth roots
$114.00
D7310
Alveoloplasty in conjunction w/ extractions—per quad
$125.00
D7311
Alveoloplasty in conjunction w/ extractions—1-3 teeth
$97.00
D7320
Alveoloplasty not conjunction w/ extractions—per quad
$181.00
D7321
Alveoloplasty not conjunction w/ extractions—1-3 teeth
$153.00
D7510
Incision and drainage of abscess— intraoral
$120.00
D7520
Incision and drainage of abscess— extraoral
$570.00
D7960
Frenulectomy—separate procedure.
$111.00
D7970
Excision of hyperplastic tissue—per arch
$272.00
D9110
Palliative treatment dental pain— minor procedure
$45.00
D9215
Local anesthesia
D9241
IV conscious sedation/analg—1st 30 minutes
$144.00
D9242
IV conscious sedation/analg—each addl 15 minutes
$60.00
Orthodontics D8070
Consultation Evaluation
D8080
D9310
Professional consultation by nontreating dentist
$96.00
D9951
Occlusal adjustment—limited
$58.00
D9952
Occlusal adjustment—complete
$326.00
D8090
$35.00 $250.00
Orthodontic treatment
$2100.00
Comprehensive Orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases no charge
Evaluation
$35.00
Records/Treatment Planning
$250.00
Orthodontic treatment
$2100.00
Comprehensive Orthodontic treatment of the transitional/adult dentition; Adults 19 years of age and older; Up to 24 months of routine orthodontic treatment for Class I and Class II cases.
Consultation
D8680
no charge
Records/Treatment Planning
Consultation
no charge
Member Pays
Comprehensive Orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
no charge
Evaluation
$35.00
Records/Treatment Planning
$250.00
Orthodontic treatment
$2300.00
Retention
$450.00
a Limit of one every six months b Limit one per tooth every eight years c Limit one every 12 months d Limit one every five years e Limit of one every three years f Limit of one every eight year Note: • Your participating general dentist and participating specialist office visit co-payment amounts, if applicable, are shown on your I.D. card. • Your office visit co-payment is applicable for all dates of service and is in addition to the co-payment amounts listed for covered dental care services. • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted covered dental care services are available at certain participating dentist’s usual fee less 20%. Visit www.HumanaDental.com to find a participating dentist who offers the discount on unlisted services. • Additional exclusions and limitations are listed along with full plan information in your Certificate of Benefits. Insured or administered by DentiCare, Inc. (d/b/a CompBenefits)
51
HUMANA
Vision
YOUR BENEFITS PACKAGE
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 52 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Vision Vision care services Exam with dilation as necessary • Retinal imaging 1 Contact lens exam options2 • Standard contact lens fit and follow-up • Premium contact lens fit and follow-up Frames3 Standard plastic lenses4 • Single vision • Bifocal • Trifocal • Lenticular Covered lens options4 • UV coating • Tint (solid and gradient) • Standard scratch-resistance • Standard polycarbonate - adults • Standard polycarbonate - children <19 • Standard anti-reflective coating • Premium anti-reflective coating - Tier 1 - Tier 2 - Tier 3 • Standard progressive (add-on to bifocal) • Premium progressive - Tier 1 - Tier 2 - Tier 3 - Tier 4 • Photochromatic / plastic transitions • Polarized Contact lenses5 (applies to materials only) • Conventional • •
If you use an IN-NETWORK provider (Member cost) $10 Up to $39
If you use an OUT-OF NETWORK provider (Reimbursement) Up to $30 Not covered
Up to $55 10% off retail
Not covered Not covered
$130 allowance; 20% off balance over $130
$65 allowance
$15 $15 $15 $15
Up to $25 Up to $40 Up to $60 Up to $100
$15 $15 $15 $40 $40 $45 Premium anti-reflective coatings as follows:
Not covered Not covered Not covered Not covered Not covered Not covered Premium anti-reflective coatings as follows: Not covered Not covered Not covered Up to $40 Premium progressives as follows: Not covered Not covered Not covered Not covered Not covered Not covered
$57 $68 80% of charge $15 Premium progressives as follows: $110 $120 $135 $90 copay, 80% of charge less $120 allowance $75 20% off retail $130 allowance, 15% off balance over $130 $130 allowance $0
Disposable Medically necessary Frequency • Examination • Lenses or contact lenses • Frame Diabetic Eye Care: care and testing for diabetic members • Examination -Up to (2) services per year • Retinal Imaging -Up to (2) services per year • Extended Ophthalmoscopy -Up to (2) services per year • Gonioscopy - Up to (2) services per year • Scanning Laser -Up to (2) services per year
$104 allowance $104 allowance $200 allowance
Once every 12 months Once every 12 months Once every 24 months
Once every 12 months Once every 12 months Once every 24 months
$0
Up to $77
$0
Up to $50
$0
Up to $15
$0
Up to $15
$0
Up to $33
53
Vision 1.
Member costs may exceed $39 with certain providers. Members may contact their participating provider to determine what costs or discounts are available. 2 Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by participating provider. Members may contact their participating provider to determine what costs or discounts are available. 3 Discounts may be available on all frames except when prohibited by the manufacturer. 4 Lens option costs may vary by provider. Members may contact their participating provider to determine if listed costs are available. 5 Plan covers contact lenses or frames, but not both, unless you have the Eye Glass and Contact Lens Rider.
Additional plan discounts •Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMed Provider’s professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. Services or materials provided by any other group benefit plan providing vision care may not be covered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes a no-discount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair of eyeglasses. If purchased separately, members receive 20% off the retail price. •Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US Laser Network, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure, performed by specialty trained providers, this discount may not always be available from a provider in your immediate location.
Limitations and Exclusions: In addition to the limitations and exclusions listed in your "Vision Benefits" section, this policy does not provide benefits for the following: 1. Any expenses incurred while you qualify for any worker’s compensation or occupational disease act or law, whether or not you applied for coverage. 2. Services: •That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law; •Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or •Furnished by any U.S. government-owned or operated hospital/institution/ agency for any service connected with sickness or bodily injury. 3. Any loss caused or contributed by: •War or any act of war, whether declared or not; •Any act of international armed conflict; or •Any conflict involving armed forces of any international authority. 4. Any expense arising from the completion of forms. 5. Your failure to keep an appointment. 6. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist. 7. Prescription drugs or pre-medications, whether dispensed or prescribed. 8. Any service not specifically listed in the Schedule of Benefits. 9. Any service that we determine: •Is not a visual necessity; •Does not offer a favorable prognosis; •Does not have uniform professional endorsement; or •Is deemed to be experimental or investigational in nature. 10. Orthoptic or vision training. 11. Subnormal vision aids and associated testing. 12. Aniseikonic lenses. 13. Any service we consider cosmetic.
54
14. Any expense incurred before your effective date or after the date your coverage under this policy terminates. 15. Services provided by someone who ordinarily lives in your home or who is a family member. 16. Charges exceeding the reimbursement limit for the service. 17. Treatment resulting from any intentionally self-inflicted injury or bodily illness. 18. Plano lenses. 19. Medical or surgical treatment of eye, eyes, or supporting structures. 20. Replacement of lenses or frames furnished under this plan which are lost or broken, unless otherwise available under the plan. 21. Any examination or material required by an Employer as a condition of employment. 22. Non-prescription sunglasses. 23. Two pair of glasses in lieu of bifocals. 24. Services or materials provided by any other group benefit plans providing vision care. 25. Certain name brands when manufacturer imposes no discount. 26. Corrective vision treatment of an experimental nature. 27. Solutions and/or cleaning products for glasses or contact lenses. 28. Pathological treatment. 29. Non-prescription items. 30. Costs associated with securing materials. 31. Pre- and Post-operative services. 32. Orthokeratology. 33. Routine maintenance of materials. 34. Refitting or change in lens design after initial fitting, unless specifically allowed elsewhere in the certificate. 35. Artistically painted lenses.
Vision
55
THE HARTFORD YOUR BENEFITS PACKAGE
Disability
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 56 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Long Term Disability What is Long-Term Disability Insurance? Long-Term Disability Insurance pays you a portion of your earnings if you cannot work because of a disabling illness or injury. You have the opportunity to purchase Long-Term Disability Insurance through your employer. This highlight sheet is an overview of your Long-Term Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.
Why do I need Long-Term Disability Coverage? Most accidents and injuries that keep people off the job happen outside the workplace and therefore are not covered by worker’s compensation. When you consider that nearly three in 10 workers entering the workforce today will become disabled before retiring1, it’s protection you won’t want to be without. 1 Social Security Administration, Fact Sheet 2009.
What is disability? Disability is defined in The Hartford’s* contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings. Once you have been disabled for 24 months, you must be prevented from performing one or more of the essential duties of any occupation and as a result, your current monthly earnings are 66 2/3% or less of your pre-disability earnings.
Am I eligible? You are eligible if you are an active member of the Retirement System of Texas (TRS) who works at least 10 hours per week on a regularly scheduled basis, excluding temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors.
How much coverage would I have? You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $10,000 that cannot exceed 66 2/3% of your current monthly earnings. Your plan includes a minimum benefit of 20% of your elected benefit.
Earnings are defined in The Hartford’s contract with your employer.
Work with your employer on the day your coverage takes effect.
What does “Actively at Work” mean? You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.
How long do I have to wait before I can receive my benefit? You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Long-Term Disability benefit payment. For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day.
What is an elimination period? The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin.
I already have Disability coverage; do I have to do anything? If you are not changing the amount of your coverage or your elimination period option, you do not have to do anything. If you want to purchase Long-Term Disability insurance for the first time or change your coverage, please be sure to complete the online enrollment, which indicates your election.
What other benefits are included in my disability coverage? •
•
When can I enroll? If you choose not to elect coverage during your annual enrollment period, you will not be eligible to elect coverage until the next annual enrollment period without a qualifying change in family status.
When is it effective? Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at
•
Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment. Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse, or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit. The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/ elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate 57
Long Term Disability
•
•
family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services. Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services. Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.
How long will my disability payments continue? Can the duration of my benefit be reduced? Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury. Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of either the Premium or Select benefit option.
How long will my disability benefits continue if I elect the Premium benefit option? Premium Option: For the Premium benefit option – the table below applies to disabilities resulting from sickness or injury: Age Disabled Prior to Age 60 Age 60—64 Age 65—67 Age 68 and older
Benefits Payable To Age 65 60 Months To Age 70 24 months
How long will my disability benefits continue if I elect the Select benefit option? Select Option: For the Select benefit option – see the tables below for the applicable benefit duration based on whether your disability is a result of injury or sickness. Schedule for disability caused by injury: Age Disabled Prior to Age 60 Age 60—64 Age 65—67 Age 68 and older
58
Benefits Payable To Age 65 60 Months To Age 70 24 months
Schedule for disability caused by sickness: Age Disabled Benefits Payable Prior to Age 65 5 Years Age 65—69 To Age 70, but not less than 1 yr Age 69 and older 1 Year
Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: • War or act of war (declared or not) • Military service for any country engaged in war or other armed conflict • The commission of, or attempt to commit a felony • An intentionally self-inflicted injury • Any case where your being engaged in an illegal occupation was a contributing cause to your disability • You must be under the regular care of a physician to receive benefits.
Mental Illness, Alcoholism and Substance Abuse •
•
You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 12 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 12 month lifetime limit.
Pre-existing Conditions Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 12 consecutive months just prior to the effective date of this policy, your benefit payment will be limited unless; You have been insured under this policy for 24 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks. Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as: • Social Security Disability Insurance (please see next section for exceptions) • Workers' Compensation • Other employer-based Insurance coverage you may have • Unemployment benefits • Settlements or judgments for income loss • Retirement benefits that your employer fully or partially pays for (such as a pension plan.)
Long Term Disability Your benefit payments will not be reduced by certain kinds of other income, such as: • Retirement benefits if you were already receiving them before you became disabled • Retirement benefits that are funded by your after-tax contributions • The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement. • Your personal savings, investments, IRAs or Keoghs • Profit-sharing • Most personal disability policies • Social Security increases
File a Claim with Confidence Fort Worth Independent School District Policy Number 395332
To file a claim, call this number: 866-278-2655 Forth Worth ISD Policy #395332 If you’re absent from work we can advise you on when to file a claim. If your absence is scheduled, such as an upcoming hospital stay, call within 30 days of your last day of work. If unscheduled, please call us as soon as possible.
Your disability program is managed by The Hartford, a leader in disability and leave services. It’s a user-friendly benefit that provides essential support services while you’re away from your workplace
STEP 1 Know when it’s time to file. If you’re absent from work, we can advise you on when to file your claim. If your absence is scheduled, such as an upcoming hospital stay, simply call us within 30 days of your last day at work. If unscheduled, please call us as soon as possible.
STEP 2 Have this information ready. • • • • •
Name, address, policy number, and other key identification information. Name of your department and last day of active full-time work. Your manager’s or Benefits Representative’s name and phone number. The nature of your claim. Your treating physician’s name, address, and phone and fax numbers.
STEP 3 Make the call. With your information handy, call The Hartford at 1-866-2782655. You’ll be assisted by a caring professional who’ll take your information, answer your questions and file your claim.
59
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 60 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $5.64 $8.46 $11.28 $14.10 $16.92 $19.74 $22.56 $25.38 $28.20 $31.02 $33.84 $36.66 $39.48 $42.30 $45.12 $47.94 $50.76 $53.58 $56.40 $59.22 $62.04 $64.86 $67.68 $70.50 $73.32 $76.14 $78.96 $81.78 $84.60 $87.42 $90.24 $93.06 $95.88 $98.70 $101.52 $104.34 $107.16 $109.98 $112.80 $115.62 $118.44 $121.26 $124.08 $126.90 $129.72 $132.54 $135.36 $138.18 $141.00 $143.82
Ages 30-34 $6.72 $10.08 $13.44 $16.80 $20.16 $23.52 $26.88 $30.24 $33.60 $36.96 $40.32 $43.68 $47.04 $50.40 $53.76 $57.12 $60.48 $63.84 $67.20 $70.56 $73.92 $77.28 $80.64 $84.00 $87.36 $90.72 $94.08 $97.44 $100.80 $104.16 $107.52 $110.88 $114.24 $117.60 $120.96 $124.32 $127.68 $131.04 $134.40 $137.76 $141.12 $144.48 $147.84 $151.20 $154.56 $157.92 $161.28 $164.64 $168.00 $171.36
Ages 35-39 $8.14 $12.21 $16.28 $20.35 $24.42 $28.49 $32.56 $36.63 $40.70 $44.77 $48.84 $52.91 $56.98 $61.05 $65.12 $69.19 $73.26 $77.33 $81.40 $85.47 $89.54 $93.61 $97.68 $101.75 $105.82 $109.89 $113.96 $118.03 $122.10 $126.17 $130.24 $134.31 $138.38 $142.45 $146.52 $150.59 $154.66 $158.73 $162.80 $166.87 $170.94 $175.01 $179.08 $183.15 $187.22 $191.29 $195.36 $199.43 $203.50 $207.57
Ages 40-44 $8.98 $13.47 $17.96 $22.45 $26.94 $31.43 $35.92 $40.41 $44.90 $49.39 $53.88 $58.37 $62.86 $67.35 $71.84 $76.33 $80.82 $85.31 $89.80 $94.29 $98.78 $103.27 $107.76 $112.25 $116.74 $121.23 $125.72 $130.21 $134.70 $139.19 $143.68 $148.17 $152.66 $157.15 $161.64 $166.13 $170.62 $175.11 $179.60 $184.09 $188.58 $193.07 $197.56 $202.05 $206.54 $211.03 $215.52 $220.01 $224.50 $228.99
Ages 45-49 $10.36 $15.54 $20.72 $25.90 $31.08 $36.26 $41.44 $46.62 $51.80 $56.98 $62.16 $67.34 $72.52 $77.70 $82.88 $88.06 $93.24 $98.42 $103.60 $108.78 $113.96 $119.14 $124.32 $129.50 $134.68 $139.86 $145.04 $150.22 $155.40 $160.58 $165.76 $170.94 $176.12 $181.30 $186.48 $191.66 $196.84 $202.02 $207.20 $212.38 $217.56 $222.74 $227.92 $233.10 $238.28 $243.46 $248.64 $253.82 $259.00 $264.18
Ages 50-54 $12.94 $19.41 $25.88 $32.35 $38.82 $45.29 $51.76 $58.23 $64.70 $71.17 $77.64 $84.11 $90.58 $97.05 $103.52 $109.99 $116.46 $122.93 $129.40 $135.87 $142.34 $148.81 $155.28 $161.75 $168.22 $174.69 $181.16 $187.63 $194.10 $200.57 $207.04 $213.51 $219.98 $226.45 $232.92 $239.39 $245.86 $252.33 $258.80 $265.27 $271.74 $278.21 $284.68 $291.15 $297.62 $304.09 $310.56 $317.03 $323.50 $329.97
Ages 55-59 $12.98 $19.47 $25.96 $32.45 $38.94 $45.43 $51.92 $58.41 $64.90 $71.39 $77.88 $84.37 $90.86 $97.35 $103.84 $110.33 $116.82 $123.31 $129.80 $136.29 $142.78 $149.27 $155.76 $162.25 $168.74 $175.23 $181.72 $188.21 $194.70 $201.19 $207.68 $214.17 $220.66 $227.15 $233.64 $240.13 $246.62 $253.11 $259.60 $266.09 $272.58 $279.07 $285.56 $292.05 $298.54 $305.03 $311.52 $318.01 $324.50 $330.99
Ages 60+ $12.36 $18.54 $24.72 $30.90 $37.08 $43.26 $49.44 $55.62 $61.80 $67.98 $74.16 $80.34 $86.52 $92.70 $98.88 $105.06 $111.24 $117.42 $123.60 $129.78 $135.96 $142.14 $148.32 $154.50 $160.68 $166.86 $173.04 $179.22 $185.40 $191.58 $197.76 $203.94 $210.12 $216.30 $222.48 $228.66 $234.84 $241.02 $247.20 $253.38 $259.56 $265.74 $271.92 $278.10 $284.28 $290.46 $296.64 $302.82 $309.00 $315.18
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $146.64 $149.46 $152.28 $155.10 $157.92 $160.74 $163.56 $166.38 $169.20 $172.02 $174.84 $177.66 $180.48 $183.30 $186.12 $188.94 $191.76 $194.58 $197.40 $200.22 $203.04 $205.86 $208.68 $211.50 $214.32 $217.14 $219.96 $222.78 $225.60 $228.42 $231.24 $234.06 $236.88 $239.70 $242.52 $245.34 $248.16 $250.98 $253.80 $256.62 $259.44 $262.26 $265.08 $267.90 $270.72 $273.54 $276.36 $279.18 $282.00
Ages 30-34 $174.72 $178.08 $181.44 $184.80 $188.16 $191.52 $194.88 $198.24 $201.60 $204.96 $208.32 $211.68 $215.04 $218.40 $221.76 $225.12 $228.48 $231.84 $235.20 $238.56 $241.92 $245.28 $248.64 $252.00 $255.36 $258.72 $262.08 $265.44 $268.80 $272.16 $275.52 $278.88 $282.24 $285.60 $288.96 $292.32 $295.68 $299.04 $302.40 $305.76 $309.12 $312.48 $315.84 $319.20 $322.56 $325.92 $329.28 $332.64 $336.00
Ages 35-39 $211.64 $215.71 $219.78 $223.85 $227.92 $231.99 $236.06 $240.13 $244.20 $248.27 $252.34 $256.41 $260.48 $264.55 $268.62 $272.69 $276.76 $280.83 $284.90 $288.97 $293.04 $297.11 $301.18 $305.25 $309.32 $313.39 $317.46 $321.53 $325.60 $329.67 $333.74 $337.81 $341.88 $345.95 $350.02 $354.09 $358.16 $362.23 $366.30 $370.37 $374.44 $378.51 $382.58 $386.65 $390.72 $394.79 $398.86 $402.93 $407.00
Ages 40-44 $233.48 $237.97 $242.46 $246.95 $251.44 $255.93 $260.42 $264.91 $269.40 $273.89 $278.38 $282.87 $287.36 $291.85 $296.34 $300.83 $305.32 $309.81 $314.30 $318.79 $323.28 $327.77 $332.26 $336.75 $341.24 $345.73 $350.22 $354.71 $359.20 $363.69 $368.18 $372.67 $377.16 $381.65 $386.14 $390.63 $395.12 $399.61 $404.10 $408.59 $413.08 $417.57 $422.06 $426.55 $431.04 $435.53 $440.02 $444.51 $449.00
Ages 45-49 $269.36 $274.54 $279.72 $284.90 $290.08 $295.26 $300.44 $305.62 $310.80 $315.98 $321.16 $326.34 $331.52 $336.70 $341.88 $347.06 $352.24 $357.42 $362.60 $367.78 $372.96 $378.14 $383.32 $388.50 $393.68 $398.86 $404.04 $409.22 $414.40 $419.58 $424.76 $429.94 $435.12 $440.30 $445.48 $450.66 $455.84 $461.02 $466.20 $471.38 $476.56 $481.74 $486.92 $492.10 $497.28 $502.46 $507.64 $512.82 $518.00
Ages 50-54 $336.44 $342.91 $349.38 $355.85 $362.32 $368.79 $375.26 $381.73 $388.20 $394.67 $401.14 $407.61 $414.08 $420.55 $427.02 $433.49 $439.96 $446.43 $452.90 $459.37 $465.84 $472.31 $478.78 $485.25 $491.72 $498.19 $504.66 $511.13 $517.60 $524.07 $530.54 $537.01 $543.48 $549.95 $556.42 $562.89 $569.36 $575.83 $582.30 $588.77 $595.24 $601.71 $608.18 $614.65 $621.12 $627.59 $634.06 $640.53 $647.00
Ages 55-59 $337.48 $343.97 $350.46 $356.95 $363.44 $369.93 $376.42 $382.91 $389.40 $395.89 $402.38 $408.87 $415.36 $421.85 $428.34 $434.83 $441.32 $447.81 $454.30 $460.79 $467.28 $473.77 $480.26 $486.75 $493.24 $499.73 $506.22 $512.71 $519.20 $525.69 $532.18 $538.67 $545.16 $551.65 $558.14 $564.63 $571.12 $577.61 $584.10 $590.59 $597.08 $603.57 $610.06 $616.55 $623.04 $629.53 $636.02 $642.51 $649.00
Ages 60+ $321.36 $327.54 $333.72 $339.90 $346.08 $352.26 $358.44 $364.62 $370.80 $376.98 $383.16 $389.34 $395.52 $401.70 $407.88 $414.06 $420.24 $426.42 $432.60 $438.78 $444.96 $451.14 $457.32 $463.50 $469.68 $475.86 $482.04 $488.22 $494.40 $500.58 $506.76 $512.94 $519.12 $525.30 $531.48 $537.66 $543.84 $550.02 $556.20 $562.38 $568.56 $574.74 $580.92 $587.10 $593.28 $599.46 $605.64 $611.82 $618.00 61
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 62 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $4.06 $6.09 $8.12 $10.15 $12.18 $14.21 $16.24 $18.27 $20.30 $22.33 $24.36 $26.39 $28.42 $30.45 $32.48 $34.51 $36.54 $38.57 $40.60 $42.63 $44.66 $46.69 $48.72 $50.75 $52.78 $54.81 $56.84 $58.87 $60.90 $62.93 $64.96 $66.99 $69.02 $71.05 $73.08 $75.11 $77.14 $79.17 $81.20 $83.23 $85.26 $87.29 $89.32 $91.35 $93.38 $95.41 $97.44 $99.47 $101.50 $103.53
Ages 30-34 $4.82 $7.23 $9.64 $12.05 $14.46 $16.87 $19.28 $21.69 $24.10 $26.51 $28.92 $31.33 $33.74 $36.15 $38.56 $40.97 $43.38 $45.79 $48.20 $50.61 $53.02 $55.43 $57.84 $60.25 $62.66 $65.07 $67.48 $69.89 $72.30 $74.71 $77.12 $79.53 $81.94 $84.35 $86.76 $89.17 $91.58 $93.99 $96.40 $98.81 $101.22 $103.63 $106.04 $108.45 $110.86 $113.27 $115.68 $118.09 $120.50 $122.91
Ages 35-39 $5.90 $8.85 $11.80 $14.75 $17.70 $20.65 $23.60 $26.55 $29.50 $32.45 $35.40 $38.35 $41.30 $44.25 $47.20 $50.15 $53.10 $56.05 $59.00 $61.95 $64.90 $67.85 $70.80 $73.75 $76.70 $79.65 $82.60 $85.55 $88.50 $91.45 $94.40 $97.35 $100.30 $103.25 $106.20 $109.15 $112.10 $115.05 $118.00 $120.95 $123.90 $126.85 $129.80 $132.75 $135.70 $138.65 $141.60 $144.55 $147.50 $150.45
Ages 40-44 $6.66 $9.99 $13.32 $16.65 $19.98 $23.31 $26.64 $29.97 $33.30 $36.63 $39.96 $43.29 $46.62 $49.95 $53.28 $56.61 $59.94 $63.27 $66.60 $69.93 $73.26 $76.59 $79.92 $83.25 $86.58 $89.91 $93.24 $96.57 $99.90 $103.23 $106.56 $109.89 $113.22 $116.55 $119.88 $123.21 $126.54 $129.87 $133.20 $136.53 $139.86 $143.19 $146.52 $149.85 $153.18 $156.51 $159.84 $163.17 $166.50 $169.83
Ages 45-49 $7.70 $11.55 $15.40 $19.25 $23.10 $26.95 $30.80 $34.65 $38.50 $42.35 $46.20 $50.05 $53.90 $57.75 $61.60 $65.45 $69.30 $73.15 $77.00 $80.85 $84.70 $88.55 $92.40 $96.25 $100.10 $103.95 $107.80 $111.65 $115.50 $119.35 $123.20 $127.05 $130.90 $134.75 $138.60 $142.45 $146.30 $150.15 $154.00 $157.85 $161.70 $165.55 $169.40 $173.25 $177.10 $180.95 $184.80 $188.65 $192.50 $196.35
Ages 50-54 $9.60 $14.40 $19.20 $24.00 $28.80 $33.60 $38.40 $43.20 $48.00 $52.80 $57.60 $62.40 $67.20 $72.00 $76.80 $81.60 $86.40 $91.20 $96.00 $100.80 $105.60 $110.40 $115.20 $120.00 $124.80 $129.60 $134.40 $139.20 $144.00 $148.80 $153.60 $158.40 $163.20 $168.00 $172.80 $177.60 $182.40 $187.20 $192.00 $196.80 $201.60 $206.40 $211.20 $216.00 $220.80 $225.60 $230.40 $235.20 $240.00 $244.80
Ages 55-59 $9.46 $14.19 $18.92 $23.65 $28.38 $33.11 $37.84 $42.57 $47.30 $52.03 $56.76 $61.49 $66.22 $70.95 $75.68 $80.41 $85.14 $89.87 $94.60 $99.33 $104.06 $108.79 $113.52 $118.25 $122.98 $127.71 $132.44 $137.17 $141.90 $146.63 $151.36 $156.09 $160.82 $165.55 $170.28 $175.01 $179.74 $184.47 $189.20 $193.93 $198.66 $203.39 $208.12 $212.85 $217.58 $222.31 $227.04 $231.77 $236.50 $241.23
Ages 60+ $8.46 $12.69 $16.92 $21.15 $25.38 $29.61 $33.84 $38.07 $42.30 $46.53 $50.76 $54.99 $59.22 $63.45 $67.68 $71.91 $76.14 $80.37 $84.60 $88.83 $93.06 $97.29 $101.52 $105.75 $109.98 $114.21 $118.44 $122.67 $126.90 $131.13 $135.36 $139.59 $143.82 $148.05 $152.28 $156.51 $160.74 $164.97 $169.20 $173.43 $177.66 $181.89 $186.12 $190.35 $194.58 $198.81 $203.04 $207.27 $211.50 $215.73
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $105.56 $107.59 $109.62 $111.65 $113.68 $115.71 $117.74 $119.77 $121.80 $123.83 $125.86 $127.89 $129.92 $131.95 $133.98 $136.01 $138.04 $140.07 $142.10 $144.13 $146.16 $148.19 $150.22 $152.25 $154.28 $156.31 $158.34 $160.37 $162.40 $164.43 $166.46 $168.49 $170.52 $172.55 $174.58 $176.61 $178.64 $180.67 $182.70 $184.73 $186.76 $188.79 $190.82 $192.85 $194.88 $196.91 $198.94 $200.97 $203.00
Ages 30-34 $125.32 $127.73 $130.14 $132.55 $134.96 $137.37 $139.78 $142.19 $144.60 $147.01 $149.42 $151.83 $154.24 $156.65 $159.06 $161.47 $163.88 $166.29 $168.70 $171.11 $173.52 $175.93 $178.34 $180.75 $183.16 $185.57 $187.98 $190.39 $192.80 $195.21 $197.62 $200.03 $202.44 $204.85 $207.26 $209.67 $212.08 $214.49 $216.90 $219.31 $221.72 $224.13 $226.54 $228.95 $231.36 $233.77 $236.18 $238.59 $241.00
Ages 35-39 $153.40 $156.35 $159.30 $162.25 $165.20 $168.15 $171.10 $174.05 $177.00 $179.95 $182.90 $185.85 $188.80 $191.75 $194.70 $197.65 $200.60 $203.55 $206.50 $209.45 $212.40 $215.35 $218.30 $221.25 $224.20 $227.15 $230.10 $233.05 $236.00 $238.95 $241.90 $244.85 $247.80 $250.75 $253.70 $256.65 $259.60 $262.55 $265.50 $268.45 $271.40 $274.35 $277.30 $280.25 $283.20 $286.15 $289.10 $292.05 $295.00
Ages 40-44 $173.16 $176.49 $179.82 $183.15 $186.48 $189.81 $193.14 $196.47 $199.80 $203.13 $206.46 $209.79 $213.12 $216.45 $219.78 $223.11 $226.44 $229.77 $233.10 $236.43 $239.76 $243.09 $246.42 $249.75 $253.08 $256.41 $259.74 $263.07 $266.40 $269.73 $273.06 $276.39 $279.72 $283.05 $286.38 $289.71 $293.04 $296.37 $299.70 $303.03 $306.36 $309.69 $313.02 $316.35 $319.68 $323.01 $326.34 $329.67 $333.00
Ages 45-49 $200.20 $204.05 $207.90 $211.75 $215.60 $219.45 $223.30 $227.15 $231.00 $234.85 $238.70 $242.55 $246.40 $250.25 $254.10 $257.95 $261.80 $265.65 $269.50 $273.35 $277.20 $281.05 $284.90 $288.75 $292.60 $296.45 $300.30 $304.15 $308.00 $311.85 $315.70 $319.55 $323.40 $327.25 $331.10 $334.95 $338.80 $342.65 $346.50 $350.35 $354.20 $358.05 $361.90 $365.75 $369.60 $373.45 $377.30 $381.15 $385.00
Ages 50-54 $249.60 $254.40 $259.20 $264.00 $268.80 $273.60 $278.40 $283.20 $288.00 $292.80 $297.60 $302.40 $307.20 $312.00 $316.80 $321.60 $326.40 $331.20 $336.00 $340.80 $345.60 $350.40 $355.20 $360.00 $364.80 $369.60 $374.40 $379.20 $384.00 $388.80 $393.60 $398.40 $403.20 $408.00 $412.80 $417.60 $422.40 $427.20 $432.00 $436.80 $441.60 $446.40 $451.20 $456.00 $460.80 $465.60 $470.40 $475.20 $480.00
Ages 55-59 $245.96 $250.69 $255.42 $260.15 $264.88 $269.61 $274.34 $279.07 $283.80 $288.53 $293.26 $297.99 $302.72 $307.45 $312.18 $316.91 $321.64 $326.37 $331.10 $335.83 $340.56 $345.29 $350.02 $354.75 $359.48 $364.21 $368.94 $373.67 $378.40 $383.13 $387.86 $392.59 $397.32 $402.05 $406.78 $411.51 $416.24 $420.97 $425.70 $430.43 $435.16 $439.89 $444.62 $449.35 $454.08 $458.81 $463.54 $468.27 $473.00
Ages 60+ $219.96 $224.19 $228.42 $232.65 $236.88 $241.11 $245.34 $249.57 $253.80 $258.03 $262.26 $266.49 $270.72 $274.95 $279.18 $283.41 $287.64 $291.87 $296.10 $300.33 $304.56 $308.79 $313.02 $317.25 $321.48 $325.71 $329.94 $334.17 $338.40 $342.63 $346.86 $351.09 $355.32 $359.55 $363.78 $368.01 $372.24 $376.47 $380.70 $384.93 $389.16 $393.39 $397.62 $401.85 $406.08 $410.31 $414.54 $418.77 $423.00 63
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 64 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $3.52 $5.28 $7.04 $8.80 $10.56 $12.32 $14.08 $15.84 $17.60 $19.36 $21.12 $22.88 $24.64 $26.40 $28.16 $29.92 $31.68 $33.44 $35.20 $36.96 $38.72 $40.48 $42.24 $44.00 $45.76 $47.52 $49.28 $51.04 $52.80 $54.56 $56.32 $58.08 $59.84 $61.60 $63.36 $65.12 $66.88 $68.64 $70.40 $72.16 $73.92 $75.68 $77.44 $79.20 $80.96 $82.72 $84.48 $86.24 $88.00 $89.76
90 Day Elimination Period – Accident and Sickness to Age 65 Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $4.18 $5.08 $5.78 $6.74 $8.38 $8.26 $6.27 $7.62 $8.67 $10.11 $12.57 $12.39 $8.36 $10.16 $11.56 $13.48 $16.76 $16.52 $10.45 $12.70 $14.45 $16.85 $20.95 $20.65 $12.54 $15.24 $17.34 $20.22 $25.14 $24.78 $14.63 $17.78 $20.23 $23.59 $29.33 $28.91 $16.72 $20.32 $23.12 $26.96 $33.52 $33.04 $18.81 $22.86 $26.01 $30.33 $37.71 $37.17 $20.90 $25.40 $28.90 $33.70 $41.90 $41.30 $22.99 $27.94 $31.79 $37.07 $46.09 $45.43 $25.08 $30.48 $34.68 $40.44 $50.28 $49.56 $27.17 $33.02 $37.57 $43.81 $54.47 $53.69 $29.26 $35.56 $40.46 $47.18 $58.66 $57.82 $31.35 $38.10 $43.35 $50.55 $62.85 $61.95 $33.44 $40.64 $46.24 $53.92 $67.04 $66.08 $35.53 $43.18 $49.13 $57.29 $71.23 $70.21 $37.62 $45.72 $52.02 $60.66 $75.42 $74.34 $39.71 $48.26 $54.91 $64.03 $79.61 $78.47 $41.80 $50.80 $57.80 $67.40 $83.80 $82.60 $43.89 $53.34 $60.69 $70.77 $87.99 $86.73 $45.98 $55.88 $63.58 $74.14 $92.18 $90.86 $48.07 $58.42 $66.47 $77.51 $96.37 $94.99 $50.16 $60.96 $69.36 $80.88 $100.56 $99.12 $52.25 $63.50 $72.25 $84.25 $104.75 $103.25 $54.34 $66.04 $75.14 $87.62 $108.94 $107.38 $56.43 $68.58 $78.03 $90.99 $113.13 $111.51 $58.52 $71.12 $80.92 $94.36 $117.32 $115.64 $60.61 $73.66 $83.81 $97.73 $121.51 $119.77 $62.70 $76.20 $86.70 $101.10 $125.70 $123.90 $64.79 $78.74 $89.59 $104.47 $129.89 $128.03 $66.88 $81.28 $92.48 $107.84 $134.08 $132.16 $68.97 $83.82 $95.37 $111.21 $138.27 $136.29 $71.06 $86.36 $98.26 $114.58 $142.46 $140.42 $73.15 $88.90 $101.15 $117.95 $146.65 $144.55 $75.24 $91.44 $104.04 $121.32 $150.84 $148.68 $77.33 $93.98 $106.93 $124.69 $155.03 $152.81 $79.42 $96.52 $109.82 $128.06 $159.22 $156.94 $81.51 $99.06 $112.71 $131.43 $163.41 $161.07 $83.60 $101.60 $115.60 $134.80 $167.60 $165.20 $85.69 $104.14 $118.49 $138.17 $171.79 $169.33 $87.78 $106.68 $121.38 $141.54 $175.98 $173.46 $89.87 $109.22 $124.27 $144.91 $180.17 $177.59 $91.96 $111.76 $127.16 $148.28 $184.36 $181.72 $94.05 $114.30 $130.05 $151.65 $188.55 $185.85 $96.14 $116.84 $132.94 $155.02 $192.74 $189.98 $98.23 $119.38 $135.83 $158.39 $196.93 $194.11 $100.32 $121.92 $138.72 $161.76 $201.12 $198.24 $102.41 $124.46 $141.61 $165.13 $205.31 $202.37 $104.50 $127.00 $144.50 $168.50 $209.50 $206.50 $106.59 $129.54 $147.39 $171.87 $213.69 $210.63
Ages 60+ $7.00 $10.50 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $35.00 $38.50 $42.00 $45.50 $49.00 $52.50 $56.00 $59.50 $63.00 $66.50 $70.00 $73.50 $77.00 $80.50 $84.00 $87.50 $91.00 $94.50 $98.00 $101.50 $105.00 $108.50 $112.00 $115.50 $119.00 $122.50 $126.00 $129.50 $133.00 $136.50 $140.00 $143.50 $147.00 $150.50 $154.00 $157.50 $161.00 $164.50 $168.00 $171.50 $175.00 $178.50
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $91.52 $93.28 $95.04 $96.80 $98.56 $100.32 $102.08 $103.84 $105.60 $107.36 $109.12 $110.88 $112.64 $114.40 $116.16 $117.92 $119.68 $121.44 $123.20 $124.96 $126.72 $128.48 $130.24 $132.00 $133.76 $135.52 $137.28 $139.04 $140.80 $142.56 $144.32 $146.08 $147.84 $149.60 $151.36 $153.12 $154.88 $156.64 $158.40 $160.16 $161.92 $163.68 $165.44 $167.20 $168.96 $170.72 $172.48 $174.24 $176.00
90 Day Elimination Period – Accident and Sickness to Age 65 Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $108.68 $132.08 $150.28 $175.24 $217.88 $214.76 $110.77 $134.62 $153.17 $178.61 $222.07 $218.89 $112.86 $137.16 $156.06 $181.98 $226.26 $223.02 $114.95 $139.70 $158.95 $185.35 $230.45 $227.15 $117.04 $142.24 $161.84 $188.72 $234.64 $231.28 $119.13 $144.78 $164.73 $192.09 $238.83 $235.41 $121.22 $147.32 $167.62 $195.46 $243.02 $239.54 $123.31 $149.86 $170.51 $198.83 $247.21 $243.67 $125.40 $152.40 $173.40 $202.20 $251.40 $247.80 $127.49 $154.94 $176.29 $205.57 $255.59 $251.93 $129.58 $157.48 $179.18 $208.94 $259.78 $256.06 $131.67 $160.02 $182.07 $212.31 $263.97 $260.19 $133.76 $162.56 $184.96 $215.68 $268.16 $264.32 $135.85 $165.10 $187.85 $219.05 $272.35 $268.45 $137.94 $167.64 $190.74 $222.42 $276.54 $272.58 $140.03 $170.18 $193.63 $225.79 $280.73 $276.71 $142.12 $172.72 $196.52 $229.16 $284.92 $280.84 $144.21 $175.26 $199.41 $232.53 $289.11 $284.97 $146.30 $177.80 $202.30 $235.90 $293.30 $289.10 $148.39 $180.34 $205.19 $239.27 $297.49 $293.23 $150.48 $182.88 $208.08 $242.64 $301.68 $297.36 $152.57 $185.42 $210.97 $246.01 $305.87 $301.49 $154.66 $187.96 $213.86 $249.38 $310.06 $305.62 $156.75 $190.50 $216.75 $252.75 $314.25 $309.75 $158.84 $193.04 $219.64 $256.12 $318.44 $313.88 $160.93 $195.58 $222.53 $259.49 $322.63 $318.01 $163.02 $198.12 $225.42 $262.86 $326.82 $322.14 $165.11 $200.66 $228.31 $266.23 $331.01 $326.27 $167.20 $203.20 $231.20 $269.60 $335.20 $330.40 $169.29 $205.74 $234.09 $272.97 $339.39 $334.53 $171.38 $208.28 $236.98 $276.34 $343.58 $338.66 $173.47 $210.82 $239.87 $279.71 $347.77 $342.79 $175.56 $213.36 $242.76 $283.08 $351.96 $346.92 $177.65 $215.90 $245.65 $286.45 $356.15 $351.05 $179.74 $218.44 $248.54 $289.82 $360.34 $355.18 $181.83 $220.98 $251.43 $293.19 $364.53 $359.31 $183.92 $223.52 $254.32 $296.56 $368.72 $363.44 $186.01 $226.06 $257.21 $299.93 $372.91 $367.57 $188.10 $228.60 $260.10 $303.30 $377.10 $371.70 $190.19 $231.14 $262.99 $306.67 $381.29 $375.83 $192.28 $233.68 $265.88 $310.04 $385.48 $379.96 $194.37 $236.22 $268.77 $313.41 $389.67 $384.09 $196.46 $238.76 $271.66 $316.78 $393.86 $388.22 $198.55 $241.30 $274.55 $320.15 $398.05 $392.35 $200.64 $243.84 $277.44 $323.52 $402.24 $396.48 $202.73 $246.38 $280.33 $326.89 $406.43 $400.61 $204.82 $248.92 $283.22 $330.26 $410.62 $404.74 $206.91 $251.46 $286.11 $333.63 $414.81 $408.87 $209.00 $254.00 $289.00 $337.00 $419.00 $413.00
Ages 60+ $182.00 $185.50 $189.00 $192.50 $196.00 $199.50 $203.00 $206.50 $210.00 $213.50 $217.00 $220.50 $224.00 $227.50 $231.00 $234.50 $238.00 $241.50 $245.00 $248.50 $252.00 $255.50 $259.00 $262.50 $266.00 $269.50 $273.00 $276.50 $280.00 $283.50 $287.00 $290.50 $294.00 $297.50 $301.00 $304.50 $308.00 $311.50 $315.00 $318.50 $322.00 $325.50 $329.00 $332.50 $336.00 $339.50 $343.00 $346.50 $350.00 65
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 66 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $4.44 $6.66 $8.88 $11.10 $13.32 $15.54 $17.76 $19.98 $22.20 $24.42 $26.64 $28.86 $31.08 $33.30 $35.52 $37.74 $39.96 $42.18 $44.40 $46.62 $48.84 $51.06 $53.28 $55.50 $57.72 $59.94 $62.16 $64.38 $66.60 $68.82 $71.04 $73.26 $75.48 $77.70 $79.92 $82.14 $84.36 $86.58 $88.80 $91.02 $93.24 $95.46 $97.68 $99.90 $102.12 $104.34 $106.56 $108.78 $111.00 $113.22
14 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $5.24 $6.34 $6.66 $7.46 $9.34 $10.04 $7.86 $9.51 $9.99 $11.19 $14.01 $15.06 $10.48 $12.68 $13.32 $14.92 $18.68 $20.08 $13.10 $15.85 $16.65 $18.65 $23.35 $25.10 $15.72 $19.02 $19.98 $22.38 $28.02 $30.12 $18.34 $22.19 $23.31 $26.11 $32.69 $35.14 $20.96 $25.36 $26.64 $29.84 $37.36 $40.16 $23.58 $28.53 $29.97 $33.57 $42.03 $45.18 $26.20 $31.70 $33.30 $37.30 $46.70 $50.20 $28.82 $34.87 $36.63 $41.03 $51.37 $55.22 $31.44 $38.04 $39.96 $44.76 $56.04 $60.24 $34.06 $41.21 $43.29 $48.49 $60.71 $65.26 $36.68 $44.38 $46.62 $52.22 $65.38 $70.28 $39.30 $47.55 $49.95 $55.95 $70.05 $75.30 $41.92 $50.72 $53.28 $59.68 $74.72 $80.32 $44.54 $53.89 $56.61 $63.41 $79.39 $85.34 $47.16 $57.06 $59.94 $67.14 $84.06 $90.36 $49.78 $60.23 $63.27 $70.87 $88.73 $95.38 $52.40 $63.40 $66.60 $74.60 $93.40 $100.40 $55.02 $66.57 $69.93 $78.33 $98.07 $105.42 $57.64 $69.74 $73.26 $82.06 $102.74 $110.44 $60.26 $72.91 $76.59 $85.79 $107.41 $115.46 $62.88 $76.08 $79.92 $89.52 $112.08 $120.48 $65.50 $79.25 $83.25 $93.25 $116.75 $125.50 $68.12 $82.42 $86.58 $96.98 $121.42 $130.52 $70.74 $85.59 $89.91 $100.71 $126.09 $135.54 $73.36 $88.76 $93.24 $104.44 $130.76 $140.56 $75.98 $91.93 $96.57 $108.17 $135.43 $145.58 $78.60 $95.10 $99.90 $111.90 $140.10 $150.60 $81.22 $98.27 $103.23 $115.63 $144.77 $155.62 $83.84 $101.44 $106.56 $119.36 $149.44 $160.64 $86.46 $104.61 $109.89 $123.09 $154.11 $165.66 $89.08 $107.78 $113.22 $126.82 $158.78 $170.68 $91.70 $110.95 $116.55 $130.55 $163.45 $175.70 $94.32 $114.12 $119.88 $134.28 $168.12 $180.72 $96.94 $117.29 $123.21 $138.01 $172.79 $185.74 $99.56 $120.46 $126.54 $141.74 $177.46 $190.76 $102.18 $123.63 $129.87 $145.47 $182.13 $195.78 $104.80 $126.80 $133.20 $149.20 $186.80 $200.80 $107.42 $129.97 $136.53 $152.93 $191.47 $205.82 $110.04 $133.14 $139.86 $156.66 $196.14 $210.84 $112.66 $136.31 $143.19 $160.39 $200.81 $215.86 $115.28 $139.48 $146.52 $164.12 $205.48 $220.88 $117.90 $142.65 $149.85 $167.85 $210.15 $225.90 $120.52 $145.82 $153.18 $171.58 $214.82 $230.92 $123.14 $148.99 $156.51 $175.31 $219.49 $235.94 $125.76 $152.16 $159.84 $179.04 $224.16 $240.96 $128.38 $155.33 $163.17 $182.77 $228.83 $245.98 $131.00 $158.50 $166.50 $186.50 $233.50 $251.00 $133.62 $161.67 $169.83 $190.23 $238.17 $256.02
Ages 60+ $11.52 $17.28 $23.04 $28.80 $34.56 $40.32 $46.08 $51.84 $57.60 $63.36 $69.12 $74.88 $80.64 $86.40 $92.16 $97.92 $103.68 $109.44 $115.20 $120.96 $126.72 $132.48 $138.24 $144.00 $149.76 $155.52 $161.28 $167.04 $172.80 $178.56 $184.32 $190.08 $195.84 $201.60 $207.36 $213.12 $218.88 $224.64 $230.40 $236.16 $241.92 $247.68 $253.44 $259.20 $264.96 $270.72 $276.48 $282.24 $288.00 $293.76
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $115.44 $117.66 $119.88 $122.10 $124.32 $126.54 $128.76 $130.98 $133.20 $135.42 $137.64 $139.86 $142.08 $144.30 $146.52 $148.74 $150.96 $153.18 $155.40 $157.62 $159.84 $162.06 $164.28 $166.50 $168.72 $170.94 $173.16 $175.38 $177.60 $179.82 $182.04 $184.26 $186.48 $188.70 $190.92 $193.14 $195.36 $197.58 $199.80 $202.02 $204.24 $206.46 $208.68 $210.90 $213.12 $215.34 $217.56 $219.78 $222.00
14 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $136.24 $164.84 $173.16 $193.96 $242.84 $261.04 $138.86 $168.01 $176.49 $197.69 $247.51 $266.06 $141.48 $171.18 $179.82 $201.42 $252.18 $271.08 $144.10 $174.35 $183.15 $205.15 $256.85 $276.10 $146.72 $177.52 $186.48 $208.88 $261.52 $281.12 $149.34 $180.69 $189.81 $212.61 $266.19 $286.14 $151.96 $183.86 $193.14 $216.34 $270.86 $291.16 $154.58 $187.03 $196.47 $220.07 $275.53 $296.18 $157.20 $190.20 $199.80 $223.80 $280.20 $301.20 $159.82 $193.37 $203.13 $227.53 $284.87 $306.22 $162.44 $196.54 $206.46 $231.26 $289.54 $311.24 $165.06 $199.71 $209.79 $234.99 $294.21 $316.26 $167.68 $202.88 $213.12 $238.72 $298.88 $321.28 $170.30 $206.05 $216.45 $242.45 $303.55 $326.30 $172.92 $209.22 $219.78 $246.18 $308.22 $331.32 $175.54 $212.39 $223.11 $249.91 $312.89 $336.34 $178.16 $215.56 $226.44 $253.64 $317.56 $341.36 $180.78 $218.73 $229.77 $257.37 $322.23 $346.38 $183.40 $221.90 $233.10 $261.10 $326.90 $351.40 $186.02 $225.07 $236.43 $264.83 $331.57 $356.42 $188.64 $228.24 $239.76 $268.56 $336.24 $361.44 $191.26 $231.41 $243.09 $272.29 $340.91 $366.46 $193.88 $234.58 $246.42 $276.02 $345.58 $371.48 $196.50 $237.75 $249.75 $279.75 $350.25 $376.50 $199.12 $240.92 $253.08 $283.48 $354.92 $381.52 $201.74 $244.09 $256.41 $287.21 $359.59 $386.54 $204.36 $247.26 $259.74 $290.94 $364.26 $391.56 $206.98 $250.43 $263.07 $294.67 $368.93 $396.58 $209.60 $253.60 $266.40 $298.40 $373.60 $401.60 $212.22 $256.77 $269.73 $302.13 $378.27 $406.62 $214.84 $259.94 $273.06 $305.86 $382.94 $411.64 $217.46 $263.11 $276.39 $309.59 $387.61 $416.66 $220.08 $266.28 $279.72 $313.32 $392.28 $421.68 $222.70 $269.45 $283.05 $317.05 $396.95 $426.70 $225.32 $272.62 $286.38 $320.78 $401.62 $431.72 $227.94 $275.79 $289.71 $324.51 $406.29 $436.74 $230.56 $278.96 $293.04 $328.24 $410.96 $441.76 $233.18 $282.13 $296.37 $331.97 $415.63 $446.78 $235.80 $285.30 $299.70 $335.70 $420.30 $451.80 $238.42 $288.47 $303.03 $339.43 $424.97 $456.82 $241.04 $291.64 $306.36 $343.16 $429.64 $461.84 $243.66 $294.81 $309.69 $346.89 $434.31 $466.86 $246.28 $297.98 $313.02 $350.62 $438.98 $471.88 $248.90 $301.15 $316.35 $354.35 $443.65 $476.90 $251.52 $304.32 $319.68 $358.08 $448.32 $481.92 $254.14 $307.49 $323.01 $361.81 $452.99 $486.94 $256.76 $310.66 $326.34 $365.54 $457.66 $491.96 $259.38 $313.83 $329.67 $369.27 $462.33 $496.98 $262.00 $317.00 $333.00 $373.00 $467.00 $502.00
Ages 60+ $299.52 $305.28 $311.04 $316.80 $322.56 $328.32 $334.08 $339.84 $345.60 $351.36 $357.12 $362.88 $368.64 $374.40 $380.16 $385.92 $391.68 $397.44 $403.20 $408.96 $414.72 $420.48 $426.24 $432.00 $437.76 $443.52 $449.28 $455.04 $460.80 $466.56 $472.32 $478.08 $483.84 $489.60 $495.36 $501.12 $506.88 $512.64 $518.40 $524.16 $529.92 $535.68 $541.44 $547.20 $552.96 $558.72 $564.48 $570.24 $576.00 67
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 68 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $2.92 $4.38 $5.84 $7.30 $8.76 $10.22 $11.68 $13.14 $14.60 $16.06 $17.52 $18.98 $20.44 $21.90 $23.36 $24.82 $26.28 $27.74 $29.20 $30.66 $32.12 $33.58 $35.04 $36.50 $37.96 $39.42 $40.88 $42.34 $43.80 $45.26 $46.72 $48.18 $49.64 $51.10 $52.56 $54.02 $55.48 $56.94 $58.40 $59.86 $61.32 $62.78 $64.24 $65.70 $67.16 $68.62 $70.08 $71.54 $73.00 $74.46
45 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $3.42 $4.18 $4.44 $4.94 $6.20 $6.62 $5.13 $6.27 $6.66 $7.41 $9.30 $9.93 $6.84 $8.36 $8.88 $9.88 $12.40 $13.24 $8.55 $10.45 $11.10 $12.35 $15.50 $16.55 $10.26 $12.54 $13.32 $14.82 $18.60 $19.86 $11.97 $14.63 $15.54 $17.29 $21.70 $23.17 $13.68 $16.72 $17.76 $19.76 $24.80 $26.48 $15.39 $18.81 $19.98 $22.23 $27.90 $29.79 $17.10 $20.90 $22.20 $24.70 $31.00 $33.10 $18.81 $22.99 $24.42 $27.17 $34.10 $36.41 $20.52 $25.08 $26.64 $29.64 $37.20 $39.72 $22.23 $27.17 $28.86 $32.11 $40.30 $43.03 $23.94 $29.26 $31.08 $34.58 $43.40 $46.34 $25.65 $31.35 $33.30 $37.05 $46.50 $49.65 $27.36 $33.44 $35.52 $39.52 $49.60 $52.96 $29.07 $35.53 $37.74 $41.99 $52.70 $56.27 $30.78 $37.62 $39.96 $44.46 $55.80 $59.58 $32.49 $39.71 $42.18 $46.93 $58.90 $62.89 $34.20 $41.80 $44.40 $49.40 $62.00 $66.20 $35.91 $43.89 $46.62 $51.87 $65.10 $69.51 $37.62 $45.98 $48.84 $54.34 $68.20 $72.82 $39.33 $48.07 $51.06 $56.81 $71.30 $76.13 $41.04 $50.16 $53.28 $59.28 $74.40 $79.44 $42.75 $52.25 $55.50 $61.75 $77.50 $82.75 $44.46 $54.34 $57.72 $64.22 $80.60 $86.06 $46.17 $56.43 $59.94 $66.69 $83.70 $89.37 $47.88 $58.52 $62.16 $69.16 $86.80 $92.68 $49.59 $60.61 $64.38 $71.63 $89.90 $95.99 $51.30 $62.70 $66.60 $74.10 $93.00 $99.30 $53.01 $64.79 $68.82 $76.57 $96.10 $102.61 $54.72 $66.88 $71.04 $79.04 $99.20 $105.92 $56.43 $68.97 $73.26 $81.51 $102.30 $109.23 $58.14 $71.06 $75.48 $83.98 $105.40 $112.54 $59.85 $73.15 $77.70 $86.45 $108.50 $115.85 $61.56 $75.24 $79.92 $88.92 $111.60 $119.16 $63.27 $77.33 $82.14 $91.39 $114.70 $122.47 $64.98 $79.42 $84.36 $93.86 $117.80 $125.78 $66.69 $81.51 $86.58 $96.33 $120.90 $129.09 $68.40 $83.60 $88.80 $98.80 $124.00 $132.40 $70.11 $85.69 $91.02 $101.27 $127.10 $135.71 $71.82 $87.78 $93.24 $103.74 $130.20 $139.02 $73.53 $89.87 $95.46 $106.21 $133.30 $142.33 $75.24 $91.96 $97.68 $108.68 $136.40 $145.64 $76.95 $94.05 $99.90 $111.15 $139.50 $148.95 $78.66 $96.14 $102.12 $113.62 $142.60 $152.26 $80.37 $98.23 $104.34 $116.09 $145.70 $155.57 $82.08 $100.32 $106.56 $118.56 $148.80 $158.88 $83.79 $102.41 $108.78 $121.03 $151.90 $162.19 $85.50 $104.50 $111.00 $123.50 $155.00 $165.50 $87.21 $106.59 $113.22 $125.97 $158.10 $168.81
Ages 60+ $7.66 $11.49 $15.32 $19.15 $22.98 $26.81 $30.64 $34.47 $38.30 $42.13 $45.96 $49.79 $53.62 $57.45 $61.28 $65.11 $68.94 $72.77 $76.60 $80.43 $84.26 $88.09 $91.92 $95.75 $99.58 $103.41 $107.24 $111.07 $114.90 $118.73 $122.56 $126.39 $130.22 $134.05 $137.88 $141.71 $145.54 $149.37 $153.20 $157.03 $160.86 $164.69 $168.52 $172.35 $176.18 $180.01 $183.84 $187.67 $191.50 $195.33
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $75.92 $77.38 $78.84 $80.30 $81.76 $83.22 $84.68 $86.14 $87.60 $89.06 $90.52 $91.98 $93.44 $94.90 $96.36 $97.82 $99.28 $100.74 $102.20 $103.66 $105.12 $106.58 $108.04 $109.50 $110.96 $112.42 $113.88 $115.34 $116.80 $118.26 $119.72 $121.18 $122.64 $124.10 $125.56 $127.02 $128.48 $129.94 $131.40 $132.86 $134.32 $135.78 $137.24 $138.70 $140.16 $141.62 $143.08 $144.54 $146.00
45 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $88.92 $108.68 $115.44 $128.44 $161.20 $172.12 $90.63 $110.77 $117.66 $130.91 $164.30 $175.43 $92.34 $112.86 $119.88 $133.38 $167.40 $178.74 $94.05 $114.95 $122.10 $135.85 $170.50 $182.05 $95.76 $117.04 $124.32 $138.32 $173.60 $185.36 $97.47 $119.13 $126.54 $140.79 $176.70 $188.67 $99.18 $121.22 $128.76 $143.26 $179.80 $191.98 $100.89 $123.31 $130.98 $145.73 $182.90 $195.29 $102.60 $125.40 $133.20 $148.20 $186.00 $198.60 $104.31 $127.49 $135.42 $150.67 $189.10 $201.91 $106.02 $129.58 $137.64 $153.14 $192.20 $205.22 $107.73 $131.67 $139.86 $155.61 $195.30 $208.53 $109.44 $133.76 $142.08 $158.08 $198.40 $211.84 $111.15 $135.85 $144.30 $160.55 $201.50 $215.15 $112.86 $137.94 $146.52 $163.02 $204.60 $218.46 $114.57 $140.03 $148.74 $165.49 $207.70 $221.77 $116.28 $142.12 $150.96 $167.96 $210.80 $225.08 $117.99 $144.21 $153.18 $170.43 $213.90 $228.39 $119.70 $146.30 $155.40 $172.90 $217.00 $231.70 $121.41 $148.39 $157.62 $175.37 $220.10 $235.01 $123.12 $150.48 $159.84 $177.84 $223.20 $238.32 $124.83 $152.57 $162.06 $180.31 $226.30 $241.63 $126.54 $154.66 $164.28 $182.78 $229.40 $244.94 $128.25 $156.75 $166.50 $185.25 $232.50 $248.25 $129.96 $158.84 $168.72 $187.72 $235.60 $251.56 $131.67 $160.93 $170.94 $190.19 $238.70 $254.87 $133.38 $163.02 $173.16 $192.66 $241.80 $258.18 $135.09 $165.11 $175.38 $195.13 $244.90 $261.49 $136.80 $167.20 $177.60 $197.60 $248.00 $264.80 $138.51 $169.29 $179.82 $200.07 $251.10 $268.11 $140.22 $171.38 $182.04 $202.54 $254.20 $271.42 $141.93 $173.47 $184.26 $205.01 $257.30 $274.73 $143.64 $175.56 $186.48 $207.48 $260.40 $278.04 $145.35 $177.65 $188.70 $209.95 $263.50 $281.35 $147.06 $179.74 $190.92 $212.42 $266.60 $284.66 $148.77 $181.83 $193.14 $214.89 $269.70 $287.97 $150.48 $183.92 $195.36 $217.36 $272.80 $291.28 $152.19 $186.01 $197.58 $219.83 $275.90 $294.59 $153.90 $188.10 $199.80 $222.30 $279.00 $297.90 $155.61 $190.19 $202.02 $224.77 $282.10 $301.21 $157.32 $192.28 $204.24 $227.24 $285.20 $304.52 $159.03 $194.37 $206.46 $229.71 $288.30 $307.83 $160.74 $196.46 $208.68 $232.18 $291.40 $311.14 $162.45 $198.55 $210.90 $234.65 $294.50 $314.45 $164.16 $200.64 $213.12 $237.12 $297.60 $317.76 $165.87 $202.73 $215.34 $239.59 $300.70 $321.07 $167.58 $204.82 $217.56 $242.06 $303.80 $324.38 $169.29 $206.91 $219.78 $244.53 $306.90 $327.69 $171.00 $209.00 $222.00 $247.00 $310.00 $331.00
Ages 60+ $199.16 $202.99 $206.82 $210.65 $214.48 $218.31 $222.14 $225.97 $229.80 $233.63 $237.46 $241.29 $245.12 $248.95 $252.78 $256.61 $260.44 $264.27 $268.10 $271.93 $275.76 $279.59 $283.42 $287.25 $291.08 $294.91 $298.74 $302.57 $306.40 $310.23 $314.06 $317.89 $321.72 $325.55 $329.38 $333.21 $337.04 $340.87 $344.70 $348.53 $352.36 $356.19 $360.02 $363.85 $367.68 $371.51 $375.34 $379.17 $383.00 69
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 70 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $2.38 $3.57 $4.76 $5.95 $7.14 $8.33 $9.52 $10.71 $11.90 $13.09 $14.28 $15.47 $16.66 $17.85 $19.04 $20.23 $21.42 $22.61 $23.80 $24.99 $26.18 $27.37 $28.56 $29.75 $30.94 $32.13 $33.32 $34.51 $35.70 $36.89 $38.08 $39.27 $40.46 $41.65 $42.84 $44.03 $45.22 $46.41 $47.60 $48.79 $49.98 $51.17 $52.36 $53.55 $54.74 $55.93 $57.12 $58.31 $59.50 $60.69
90 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $2.76 $3.38 $3.56 $3.98 $4.98 $5.44 $4.14 $5.07 $5.34 $5.97 $7.47 $8.16 $5.52 $6.76 $7.12 $7.96 $9.96 $10.88 $6.90 $8.45 $8.90 $9.95 $12.45 $13.60 $8.28 $10.14 $10.68 $11.94 $14.94 $16.32 $9.66 $11.83 $12.46 $13.93 $17.43 $19.04 $11.04 $13.52 $14.24 $15.92 $19.92 $21.76 $12.42 $15.21 $16.02 $17.91 $22.41 $24.48 $13.80 $16.90 $17.80 $19.90 $24.90 $27.20 $15.18 $18.59 $19.58 $21.89 $27.39 $29.92 $16.56 $20.28 $21.36 $23.88 $29.88 $32.64 $17.94 $21.97 $23.14 $25.87 $32.37 $35.36 $19.32 $23.66 $24.92 $27.86 $34.86 $38.08 $20.70 $25.35 $26.70 $29.85 $37.35 $40.80 $22.08 $27.04 $28.48 $31.84 $39.84 $43.52 $23.46 $28.73 $30.26 $33.83 $42.33 $46.24 $24.84 $30.42 $32.04 $35.82 $44.82 $48.96 $26.22 $32.11 $33.82 $37.81 $47.31 $51.68 $27.60 $33.80 $35.60 $39.80 $49.80 $54.40 $28.98 $35.49 $37.38 $41.79 $52.29 $57.12 $30.36 $37.18 $39.16 $43.78 $54.78 $59.84 $31.74 $38.87 $40.94 $45.77 $57.27 $62.56 $33.12 $40.56 $42.72 $47.76 $59.76 $65.28 $34.50 $42.25 $44.50 $49.75 $62.25 $68.00 $35.88 $43.94 $46.28 $51.74 $64.74 $70.72 $37.26 $45.63 $48.06 $53.73 $67.23 $73.44 $38.64 $47.32 $49.84 $55.72 $69.72 $76.16 $40.02 $49.01 $51.62 $57.71 $72.21 $78.88 $41.40 $50.70 $53.40 $59.70 $74.70 $81.60 $42.78 $52.39 $55.18 $61.69 $77.19 $84.32 $44.16 $54.08 $56.96 $63.68 $79.68 $87.04 $45.54 $55.77 $58.74 $65.67 $82.17 $89.76 $46.92 $57.46 $60.52 $67.66 $84.66 $92.48 $48.30 $59.15 $62.30 $69.65 $87.15 $95.20 $49.68 $60.84 $64.08 $71.64 $89.64 $97.92 $51.06 $62.53 $65.86 $73.63 $92.13 $100.64 $52.44 $64.22 $67.64 $75.62 $94.62 $103.36 $53.82 $65.91 $69.42 $77.61 $97.11 $106.08 $55.20 $67.60 $71.20 $79.60 $99.60 $108.80 $56.58 $69.29 $72.98 $81.59 $102.09 $111.52 $57.96 $70.98 $74.76 $83.58 $104.58 $114.24 $59.34 $72.67 $76.54 $85.57 $107.07 $116.96 $60.72 $74.36 $78.32 $87.56 $109.56 $119.68 $62.10 $76.05 $80.10 $89.55 $112.05 $122.40 $63.48 $77.74 $81.88 $91.54 $114.54 $125.12 $64.86 $79.43 $83.66 $93.53 $117.03 $127.84 $66.24 $81.12 $85.44 $95.52 $119.52 $130.56 $67.62 $82.81 $87.22 $97.51 $122.01 $133.28 $69.00 $84.50 $89.00 $99.50 $124.50 $136.00 $70.38 $86.19 $90.78 $101.49 $126.99 $138.72
Ages 60+ $6.20 $9.30 $12.40 $15.50 $18.60 $21.70 $24.80 $27.90 $31.00 $34.10 $37.20 $40.30 $43.40 $46.50 $49.60 $52.70 $55.80 $58.90 $62.00 $65.10 $68.20 $71.30 $74.40 $77.50 $80.60 $83.70 $86.80 $89.90 $93.00 $96.10 $99.20 $102.30 $105.40 $108.50 $111.60 $114.70 $117.80 $120.90 $124.00 $127.10 $130.20 $133.30 $136.40 $139.50 $142.60 $145.70 $148.80 $151.90 $155.00 $158.10
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $61.88 $63.07 $64.26 $65.45 $66.64 $67.83 $69.02 $70.21 $71.40 $72.59 $73.78 $74.97 $76.16 $77.35 $78.54 $79.73 $80.92 $82.11 $83.30 $84.49 $85.68 $86.87 $88.06 $89.25 $90.44 $91.63 $92.82 $94.01 $95.20 $96.39 $97.58 $98.77 $99.96 $101.15 $102.34 $103.53 $104.72 $105.91 $107.10 $108.29 $109.48 $110.67 $111.86 $113.05 $114.24 $115.43 $116.62 $117.81 $119.00
90 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $71.76 $87.88 $92.56 $103.48 $129.48 $141.44 $73.14 $89.57 $94.34 $105.47 $131.97 $144.16 $74.52 $91.26 $96.12 $107.46 $134.46 $146.88 $75.90 $92.95 $97.90 $109.45 $136.95 $149.60 $77.28 $94.64 $99.68 $111.44 $139.44 $152.32 $78.66 $96.33 $101.46 $113.43 $141.93 $155.04 $80.04 $98.02 $103.24 $115.42 $144.42 $157.76 $81.42 $99.71 $105.02 $117.41 $146.91 $160.48 $82.80 $101.40 $106.80 $119.40 $149.40 $163.20 $84.18 $103.09 $108.58 $121.39 $151.89 $165.92 $85.56 $104.78 $110.36 $123.38 $154.38 $168.64 $86.94 $106.47 $112.14 $125.37 $156.87 $171.36 $88.32 $108.16 $113.92 $127.36 $159.36 $174.08 $89.70 $109.85 $115.70 $129.35 $161.85 $176.80 $91.08 $111.54 $117.48 $131.34 $164.34 $179.52 $92.46 $113.23 $119.26 $133.33 $166.83 $182.24 $93.84 $114.92 $121.04 $135.32 $169.32 $184.96 $95.22 $116.61 $122.82 $137.31 $171.81 $187.68 $96.60 $118.30 $124.60 $139.30 $174.30 $190.40 $97.98 $119.99 $126.38 $141.29 $176.79 $193.12 $99.36 $121.68 $128.16 $143.28 $179.28 $195.84 $100.74 $123.37 $129.94 $145.27 $181.77 $198.56 $102.12 $125.06 $131.72 $147.26 $184.26 $201.28 $103.50 $126.75 $133.50 $149.25 $186.75 $204.00 $104.88 $128.44 $135.28 $151.24 $189.24 $206.72 $106.26 $130.13 $137.06 $153.23 $191.73 $209.44 $107.64 $131.82 $138.84 $155.22 $194.22 $212.16 $109.02 $133.51 $140.62 $157.21 $196.71 $214.88 $110.40 $135.20 $142.40 $159.20 $199.20 $217.60 $111.78 $136.89 $144.18 $161.19 $201.69 $220.32 $113.16 $138.58 $145.96 $163.18 $204.18 $223.04 $114.54 $140.27 $147.74 $165.17 $206.67 $225.76 $115.92 $141.96 $149.52 $167.16 $209.16 $228.48 $117.30 $143.65 $151.30 $169.15 $211.65 $231.20 $118.68 $145.34 $153.08 $171.14 $214.14 $233.92 $120.06 $147.03 $154.86 $173.13 $216.63 $236.64 $121.44 $148.72 $156.64 $175.12 $219.12 $239.36 $122.82 $150.41 $158.42 $177.11 $221.61 $242.08 $124.20 $152.10 $160.20 $179.10 $224.10 $244.80 $125.58 $153.79 $161.98 $181.09 $226.59 $247.52 $126.96 $155.48 $163.76 $183.08 $229.08 $250.24 $128.34 $157.17 $165.54 $185.07 $231.57 $252.96 $129.72 $158.86 $167.32 $187.06 $234.06 $255.68 $131.10 $160.55 $169.10 $189.05 $236.55 $258.40 $132.48 $162.24 $170.88 $191.04 $239.04 $261.12 $133.86 $163.93 $172.66 $193.03 $241.53 $263.84 $135.24 $165.62 $174.44 $195.02 $244.02 $266.56 $136.62 $167.31 $176.22 $197.01 $246.51 $269.28 $138.00 $169.00 $178.00 $199.00 $249.00 $272.00
Ages 60+ $161.20 $164.30 $167.40 $170.50 $173.60 $176.70 $179.80 $182.90 $186.00 $189.10 $192.20 $195.30 $198.40 $201.50 $204.60 $207.70 $210.80 $213.90 $217.00 $220.10 $223.20 $226.30 $229.40 $232.50 $235.60 $238.70 $241.80 $244.90 $248.00 $251.10 $254.20 $257.30 $260.40 $263.50 $266.60 $269.70 $272.80 $275.90 $279.00 $282.10 $285.20 $288.30 $291.40 $294.50 $297.60 $300.70 $303.80 $306.90 $310.00 71
AMERICAN PUBLIC LIFE
Cancer
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.
YOUR BENEFITS PACKAGE
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 72 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
GC14 Limited Benefit Group Cancer Indemnity Insurance Fort Worth Independent School District 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 NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Summary of Benefits
Plan 1
Plan 2
Cancer Treatment Policy Benefits
Level 3
Level 4
Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period Hormone Therapy - Maximum of 12 treatments per calendar year
$15,000
$20,000
$50 per treatment
$50 per treatment
Experimental Treatment Cancer Screening Rider Benefits
paid in same manner and under the same maximums as any other benefit Level 1 Level 1
Diagnostic Testing - 1 test per calendar year
$50 per test
$50 per test
Follow-Up Diagnostic Testing - 1 test per calendar year
$100 per test
$100 per test
Medical Imaging - 1 test per calendar year
$500 per test
$500 per test
Internal Cancer First Occurrence Rider Benefits
Level 2
Level 4
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$5,000
$10,000
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$7,500
$15,000
Heart Attack/Stroke First Occurrence Rider Benefits
Level 2
Level 4
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$5,000
$10,000
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$7,500
$15,000
Total Monthly Premiums by Plan** Issue Ages 18 +
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Plan 1
Plan 2
Plan 1
Plan 2
Plan 1
Plan 2
Plan 1
Plan 2
$15.66
$25.00
$33.38
$53.84
$18.30
$29.10
$36.02
$57.98
**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.
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GC14 Limited Benefit Group Cancer Indemnity Insurance Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.
Cancer Treatment Benefits Eligibility
You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.
Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.
Only Loss for Cancer
The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, the time limit on certain defenses and preexisting condition exclusion for such increase will be based on the effective date of such increase.
Waiting Period
The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium. If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.
Termination of Certificate
Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.
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Termination of Coverage
Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.
Cancer Screening Benefits Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.
Termination of Cancer Screening Benefit Rider The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.
Internal Cancer First Occurrence Benefits Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
Limitations and Exclusions
We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.
Waiting Period
This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.
GC14 Limited Benefit Group Cancer Indemnity Insurance Heart Attack/Stroke First Occurrence Benefits Optionally Renewable Pays a lump sum benefit amount when a covered person receives a first diagnosis of heart attack or stroke and the date of diagnosis occurs after the waiting period. Only one benefit per covered person per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.
Limitations and Exclusions
When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.
We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a Pre-Existing Condition.
Waiting Period
This rider contains a 30-day waiting period during which no benefits will be paid. If any heart attack or stroke is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date.
Portability (Voluntary Plans Only)
The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of a covered person’s death or the date the lump sum benefit amount for heart attack or stroke has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent, as defined in the policy.
2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/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 GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | Fort Worth ISD 75
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METLIFE
Life and AD&D
YOUR BENEFITS PACKAGE
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 76 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Life and AD&D Fort Worth Independent School District Active Employee Life Plan Benefits Explore the coverage that makes it easy to give yourself and your loved ones more security today…and in the future.
Basic Term Life Insurance Your employer provides you with Basic Term Life insurance coverage in the amount of $5,000.00.
Supplemental Term Life Insurance Coverage Options For You
For Your Spouse and Your Dependent Children
An amount that is elected by you that is a multiple of $10,000 to a maximum of $250,000. Plan B (Only available to employees enrolled in Plan B prior to September 1, 2007) For Your Spouse: $10,000 For each of Your Children: $5,000 Plan C For Your Spouse: $20,000 For each of Your Children: $10,000 Plan D For Your Spouse: $30,000 For each of Your Children: $15,000
*Child(ren)’s Eligibility: Dependent children ages from birth to 26 years old are eligible for coverage, regardless of student status.
Monthly Costs* for Supplemental Term Life Insurance and Accidental Death and Dismemberment Insurance You have the option to purchase Supplemental Term Life Insurance. Listed below are your monthly rates as well as those for your spouse (based on your age and the amount of coverage you want). Rates to cover your child(ren) are also shown. *Note: rates are subject to the policy’s right to change premium rates, and the employer’s right to change employee contributions.
Age
Monthly Cost Per $1,000 of Employee Coverage
Monthly Cost of Spouse and Child(ren) Coverage†
$0.076 $0.235 $0.235 $0.311 $0.625 $0.879 $0.956
Plan B: $3.00 Plan C: $5.00 Plan D: $9.38
0 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64 65 + † Covers all eligible children
Use the table below to calculate your premium based on the amount of life insurance you will need. Example: $100,000 Supplemental Life Coverage 1. Enter the rate from the table (example age 36)
$0.076
2. Enter the amount of insurance in thousands of dollars (Example: for $100,000 of coverage enter $100)
3. Monthly premium (1) x (2)
100
$7.60
$ ________
________
$ ________
Repeat the three easy steps above to determine the cost for each coverage selected. 77
Life and AD&D MetLife AdvantagesSM Grief Counseling Employer Reference Guide Grief counseling services are offered with MetLife’s life insurance coverage. Whether it’s help coping with a loss or a major life change, the professional counselors and services we offer through LifeWorks, are ready to support you, your employees and their families to move forward.1 Confidential 24/7 support for employees Call 1-888-319-7819 or visit metlifegc.lifeworks.com User Name: metlifeassist Password: support Professional support for when: • a loved one has died • a divorce is finalized • a serious medical diagnosis or critical illness has occurred • a layoff or termination of a job has occurred These counseling sessions are tailored to meet individual needs. Up to 5 in-person or telephonic sessions are available with a licensed LifeWorks counselor.
Confidential legal and financial consultation • Access to a LifeWorks in-house attorney for a 30 minute consultation to assist with making informed decisions as it pertains to a loss • 1 hour consultation with a certified financial planner to assist with education, strategies and options Resources available LifeWorks offers online, self-help resources to assist with the grieving process, providing support for: • End-of-life issues • What to do after the death of a loved one • Dealing with grief Funeral assistance services Through private sessions, counselors can help employees, their loved ones and beneficiaries with funeral arrangements. They can provide referrals and helpful information about: • Nearby funeral homes and cemetery options • Funeral cost estimates from local providers • Service providers such as florists, caterers and hotels • Funeral and memorial planning • Adult care for surviving elders • Dealing with becoming a single parent • Back-up care for children or elderly • Notifying the Social Security Administration, banks, and utilities • Local support groups LifeWorks onsite support services for employers • A comprehensive trauma management service provided by specially trained consultants is available 24/7, 365 days a year via the LifeWorks toll free line. Critical Incident Stress Management (CISM) services include: • Management consultation 78
•
•
Coordination for onsite critical incident response for events* including: sudden death anticipatory grief workplace violence/accidents/disasters natural disasters Standard response time is within 24 hours. Rapid response or extra services are available at an additional cost.
*Up to 4 hours per incident per location using standard deployment are included.
Request onsite support in three simple steps Step 1: Call LifeWorks toll-free at 1-888-319-7819 to request onsite support. Step 2: A LifeWorks Service Advisor will gather preliminary information, including: • Company name • Demographic information (e.g. – name, contact number (s), email address, role) • Nature of the incident Step 3: You will be connected to a specialty team member for further assessment. In cases where an immediate transfer cannot be made, a callback will be scheduled for within 20 minutes. Services Rate Schedule Additional services are available by request at the rates listed below. Service Description
Rate
Billing Event
CISM – Rapid Response within 2 hours of request
$315.00
Per Hour
CISM – Standard Response within 24 hours of request for additional counselors and/or locations (2 hour minimum)
$230.00
Per Hour
1.
Grief Counseling and Funeral Assistance services are provided through an agreement with LifeWorks. US Inc. LifeWorks is not an affiliate of MetLife, and the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationwide network of over 30,000 counselors. Counselors have master’s or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a finalized divorce). For such issues, members should inquire with their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurred. Services are not available in all jurisdictions and are subject to regulatory approval. Not available on all policy forms
Life and AD&D Additional Features This insurance offering from your employer and MetLife comes with additional features that can provide assistance to you and your family. Accelerated Benefits Option12 For access to funds during a difficult time. If you become terminally ill and are diagnosed with 24 months or less to live, you have the option to receive up to 80% of your life insurance proceeds. This can go a long way towards helping your family meet medical and other expenses at a difficult time. Amounts not accelerated will continue under your employer’s plan for as long as you remain eligible per the certificate requirements and the group policy remains in effect. The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable tax treatment under Section 101(g) of the Internal Revenue Code (26 U.S.C.Sec 101(g)).12 Accelerated Benefits Option is not the same as long term care insurance (LTC). LTC provides nursing home care, home-health care, personal or adult day care for individuals above age 65 or with chronic or disabling conditions that require constant supervision. The Accelerated Benefits Option is also available to spouses insured under Dependent Life insurance plans. This option is not available for dependent child coverage. Conversion For protection after your coverage terminates. You can generally convert your group term life insurance benefits to an individual whole life insurance policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or change in employee class. Conversion is available on all group life insurance coverages. Please note that conversion is not available on AD&D coverage. If you experience an event that makes you eligible to convert your coverage, you can speak with a representative by calling: 1-877275-6387. Please contact your employer for more information. Waiver of Premiums for Total Disability (Continued Protection) Offering continued coverage when you need it most. If you become Totally Disabled, you may qualify to continue certain insurance. You may also be eligible for waiver of your supplemental term life insurance premium until you reach age 65, die, or recover from your disability, whichever is sooner. Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are fit by education, training or experience due to injury or sickness. The Total Disability must begin before age 60, and your waiver will begin after you have satisfied a 9-month waiting period of continuous
disability. The waiver of premium will end when you turn age 65, die, or recover. Please note that this benefit is only available after you have participated in the supplemental term life plan for one year and it is not available on dependent coverage. Premium Pay Continued premium payments during a total disability. If you become totally disabled, your employer will continue to make premium payments on your behalf for 12 months in order to keep your Basic Life coverage active. Your disability status will be determined by your employer. This provision allows coverage for you as a disabled employee to be continued as if you were still active.
What’s Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance does not provide payment of benefits for death caused by suicide within the first two years (one year for group policies issued in Missouri, North Dakota and Colorado) of the effective date of the certificate or an increase in coverage. This exclusionary period is one year for residents of Missouri and North Dakota. If the group policy was issued in Massachusetts, the suicide exclusion does not apply to dependent life coverage. The suicide exclusion does not apply to residents of Washington, or to individuals covered under a group policy issued in Washington. Please note that a reduction schedule may apply. Please see your employer or certificate for specific details.
Accidental Death & Dismemberment Coverage Options Accidental Death & Dismemberment (AD&D) coverage complements your Supplemental Life coverage insurance and helps protect you 24 hours a day, 365 days a year. This valuable coverage benefits beyond your disability or life insurance for losses due to covered accidents — including while commuting, traveling by public or private transportation and during business trips. MetLife’s AD&D insurance pays you benefits if you suffer a covered accident that results in paralysis or the loss of a limb, speech, hearing or sight, or brain damage or coma. If you suffer a covered fatal accident, benefits will be paid to your beneficiary.
Supplemental AD&D Coverage Amounts for You Your Supplemental AD&D amount is equal to your Supplemental Term Life amount. Covered Losses This AD&D insurance pays benefits for covered losses that are the result of an accidental injury or loss of life. The full 79
Life and AD&D amount of AD&D coverage you select is called the “Full Amount” and is equal to the benefit payable for the loss of life. Benefits for other losses are payable as a predetermined percentage of the Full Amount, and will be listed in your coverage in a table of Covered Losses. Such losses include loss of limbs, sight, speech and hearing, various forms of paralysis, brain damage and coma. The maximum amount payable for all Covered Losses sustained in any one accident is capped at 100% of the Full Amount. Standard Additional Benefits Include Some of the standard additional benefits included in your coverage that may increase the amounts payable to you and/ or defray additional expenses that result from accidental injury or loss of life are: • • • • • • •
Air Bag Seat Belt Common Carrier Child Care Center Child Education Spouse Education Hospitalization
What Is Not Covered? Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or active participation in a riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.
Additional Coverage Information How To Apply* Complete your enrollment form and return it to your Employee Benefits Representative today! Be sure to indicate your Beneficiary. Act Now During the Enrollment Period. Note: If you do not wish to make a change to your coverage, you do not need to do anything. 80
*All applications are subject to review and approval by Metropolitan Life Insurance Company. Based on the plan design and the amount of coverage requested, a Statement of Health may need to be submitted to complete your application.
For Employee Coverage Enrollment in this Supplemental Term Life insurance plan is available without providing medical information as long as: For Annual Enrollment • The enrollment takes place prior to the enrollment deadline, and • You are continuing the coverage you had in the last year. For New Hires • The enrollment takes place within 31 days from the date you become eligible for benefits, and • You are enrolling for coverage equal to/less than $100,000. If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.
For Dependent Coverage You must be covered in order to obtain coverage for your spouse and child(ren). Your spouse and dependent children do not need to provide medical information as long as they are not home or hospital confined and not receiving or applying to receive disability payments and: For Annual Enrollment • The enrollment takes place prior to the enrollment deadline, and • You are continuing the coverage you had for your spouse and child(ren) in the last year
For New Hires • The enrollment takes place within 31 days from the date you become eligible for benefits. If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.
About Your Coverage Effective Date You must be Actively at Work on the date your coverage becomes effective. Your coverage must be in effect in order for your spouse’s and eligible children’s coverage to take effect. In addition, your spouse and eligible child(ren) must not be home or hospital confined or receiving or applying to receive disability benefits from any source when their coverage becomes effective. If Actively at Work requirements are met, coverage will become effective on the date of hire for Basic Life and on the first of the
Life and AD&D month following the receipt of your completed application for all Supplemental and Dependent Life requests that do not require additional medical information. A request for Your amount that requires additional medical information and is not approved by the date listed above will not be effective until the later of the date that notice is received that MetLife has approved the coverage or increase if you meet Actively at Work requirements on that date, or the date that Actively at Work requirements are met after MetLife has approved the coverage or increase. The coverage for your spouse and eligible child (ren) will take effect on the date they are no longer confined, receiving or applying for disability benefits from any source or hospitalized.
Who Can Be A Designated Beneficiary? You can select any beneficiary(ies) other than your employer for your Basic and Supplemental coverages, and you may change your beneficiary(ies) at any time. You can also designate more than one beneficiary. You are the beneficiary for your Dependent coverage. 1
Grief Counseling and Funeral Planning services are provided through an agreement with Harris, Rothenberg International (HRI), Inc. HRI is not an affiliate of MetLife, and the services HRI provides are separate and apart from the insurance provided by MetLife. HRI has a nationwide network of 46,700 counselors. Counselors have master’s or doctoral degrees and are licensed professionals. Subject to state regulatory approval, not approved in all states. The grief counseling program does not provide support for issues such as domestic issues, parenting issues, or marital/ relationship issues (other than a finalized divorce). For such issues, members should inquire with their human resources departments about available company resources. This program is available to a insureds, their dependents and beneficiaries, who must have received a serious medical diagnosis or suffered a loss that has occurred, meaning, the diagnosis or loss must have taken place prior to accessing the grief counseling program. Events that may result in a loss are not covered under this program unless and until such loss has occurred.
provided by MetLife. The WillsCenter.com service does not provide access to an attorney, does not provide legal advice, and may not be suitable for your specific needs. Please consult with your financial, legal, and tax advisors for advice with respect to such matters. 12
The Accelerated Benefits Option is subject to state availability and regulation. The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances. Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family.
This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and Fort Worth Independent School District and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the booklet certificate. Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminate when your employment ceases, when your Life and AD&D contributions cease, or upon termination of the group contract. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent or when your coverage terminates. Should your life insurance coverage terminate for reasons other than nonpayment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.
4
The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCAs are maintained in MetLife’s general account and are subject to claims of MetLife’s creditors. MetLife bears the investment risk of the assets backing TCAs, and expects to receive a profit. Regardless of the investment experience of such assets, the interest credited to TCAs will never fall below the guaranteed minimum rate. Guarantees are subject to the financial strength and claims paying ability of MetLife. 6
Will Preparation Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, Will Preparation services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation. Tax Planning and preparation of Living Trusts are not covered by the Will Preparation Service. 7
Estate Resolution Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, Estate Resolution Services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. The following are not covered by the Estate Resolution Service: Matters in which there is a conflict of interest between the executor, administrator, any beneficiary or heir and the estate; any disputes with the Policyholder, Employer, Plan Attorneys, MetLife and/or any of its affiliates; any disputes involving statutory benefits; Will contests or litigation outside Probate Court; Appeals; Court costs, filing fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or fines; and frivolous or unethical matters. 8
WillsCenter.com is a document service provided by SmartLegalForms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not affiliated with MetLife and the WillsCenter.com service is separate and apart from any insurance or service
81
Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally. Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals. Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us. Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses. How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources. We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense: Ask for a medical exam Ask for blood and urine tests Ask health care providers to give us health data, including information about alcohol or drug abuse We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about: Finances Reputation Driving record Work and work history Hobbies and dangerous activities The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency. Another source of information is MIB Group, Inc. (“MIB”). It is a non-profit association of life insurance companies. We and our reinsurers may give MIB health or other information about you. If you apply for life or health coverage from another member of MIB, or claim benefits from another member company, MIB will give that company any information that it has about you. If you contact MIB, it will tell you what it knows about you. You have the right to ask MIB to correct its information about you. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734, by calling MIB at (866) 692-6901 (TTY (866) 346-3642 for the hearing impaired), or by contacting MIB at www.mib.com. Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to: CPN–Group–Initial Enr/SOH-2015 82
administer your products and services perform business research market new products to you comply with applicable laws
process claims and other transactions confirm or correct your information help us run our business
Sharing Your Information With Others We may share your personal information with others with your consent, by agreement, or as permitted or required by law. We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out. Other reasons we may share your information include:
doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) telling another company what we know about you if we are selling or merging any part of our business giving information to a governmental agency so it can decide if you are eligible for public benefits giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account) giving your information to your health care provider having a peer review organization evaluate your information, if you have health coverage with us those listed in our “Using Your Information” section above HIPAA We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you. You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAprivacyAmericasUS@metlife.com, or call us at telephone number (212) 578-0299. Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law. If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife. Questions We want you to understand how we protect your privacy. If you have any questions or want more information about this notice, please contact us. When you write, include your name, address, and policy or account number. Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI 02887-9954 privacy@metlife.com We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies: Metropolitan Life Insurance Company MetLife Health Plans, Inc. MetLife Insurance Company USA General American Life Insurance Company SafeGuard Health Plans, Inc. SafeHealth Life Insurance Company CPN–Group–Initial Enr/SOH-2015 83
INSTRUCTIONS
FOR THE STATEMENT OF HEALTH FORM AND THE AUTHORIZATION FORM THAT FOLLOW THIS SECTION INSTRUCTIONS TO THE RECORDKEEPER (The Recordkeeper may be the Group Customer, a Third Party Administrator or MetLife.) 1. Fill in the Group Customer Information and Insurance Information on the Statement of Health form. 2. Give the forms to the Employee. INSTRUCTIONS TO THE EMPLOYEE 1. Fill in your name and Social Security # on the Statement of Health form. The Employee's Name and the Employee’s Social Security # must appear on the form. 2. Give the forms to the Proposed Insured to complete and send to MetLife. INSTRUCTIONS TO THE PROPOSED INSURED (The Proposed Insured is the person for whom insurance is being requested. The Proposed Insured may be the Employee, the Employee’s Spouse or the Employee’s Child.) A separate Statement of Health form must be completed by each Proposed Insured. Based on the enrollment form submitted by the Employee, a Statement of Health form is required to complete the employee’s request for group insurance coverage for you, the Proposed Insured. 1. If the Insurance Information Section is not completed, obtain the information before finalizing the form. Contact Metropolitan Life Insurance Company your Employer/Benefits Administrator if the Life Insurance amounts were not provided or to confirm the Life Statement of Health Unit Insurance amounts. P.O. Box 14069 2. Complete the Statement of Health form and sign where indicated by an arrow. Lexington, KY 40512-4069 3. Sign the Authorization form where indicated by an arrow. FAX: 1-859-225-7909 4. After completion, make a copy of both completed forms for your records and FAX, MAIL or EMAIL the original To Submit Completed Forms Email: forms to the address at the right. Emailed forms must be printed and signed before they are scanned and SOHSubmissions@metlife.com submitted. For Questions Email: eoi@metlife.com For questions, call MetLife at 1-800-638-6420, prompt 1 (Statement of Health Unit) or email us at eoi@metlife.com. Note: Additional medical information may be required after MetLife’s initial review of a completed Statement of Health form. The additional information requested may be a physical examination, paramedical exam, or an Attending Physician Report. Correspondence will be sent within ten days by MetLife or our approved vendor. Incomplete forms will be returned to you for completion. Some services in connection with your Statement of Health form may be performed by our affiliate, MetLife Global Operations Support Center Private Limited. This service arrangement in no way alters Metropolitan Life Insurance Company's obligations to you. Services will not be performed by our affiliate if prohibited by state or local law or by mutual agreement with the Group Customer.
STATEMENT OF HEALTH FORM
Metropolitan Life Insurance Company, New York, NY
GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer/Association Fort Worth Independent School District Street Address
Group Customer # 122673 State
City
INSURANCE INFORMATION (To be Completed by the Recordkeeper)
Reporting Location # Zip Code Enrollment year
Term Life Insurance Basic Life: Indicate amount subject to medical underwriting $ Supplemental/Optional Life: Indicate amount subject to medical underwriting $ Dependent Spouse 1 Life: Indicate amount subject to medical underwriting $ Dependent Child Life: Indicate amount subject to medical underwriting $
EMPLOYEE INFORMATION (To be Completed by the Employee) Name of Employee (First, Middle, Last)
Social Security # of Employee
YOUR INFORMATION (To be Completed by the Proposed Insured) Name (First, Middle, Last) Street Address Date of Birth (MM/DD/YYYY) 1
City Daytime Phone #
Home Phone #
Relationship to Employee Self Spouse Child State
Male Female Zip Code
Email Address
For Vermont and Washington State residents, Spouse includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available.
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HEALTH INFORMATION SECTION 1 Please complete all questions below. Omitted information will cause delays. In this section, “you” and “your” refers to the person for whom insurance is being requested. Health Information is required for the Proposed Insured only. For questions 5 through 11u, for “yes” answers, please provide full details in Section 2. Your name
Employee’s Name Employee’s Social Security/Identification #
1. Your height
feet
inches
Your weight
pounds
Yes
No
2. Are you now on a diet prescribed by a physician or other health care provider? If “yes” indicate type 3. Are you now pregnant? If “yes,” what is your due date (month/day/year)? If “yes”, provide Physician’s name
Telephone: (
)
–
4. Are you now, or have you in the past 2 years, used tobacco in any form? 5. In the past 5 years, have you received medical treatment or counseling by a physician or other health care provider for, or been advised by a physician or other health care provider to discontinue, the use of alcohol or prescribed or non-prescribed drugs? 6. In the past 5 years, have you been convicted of driving while intoxicated or under the influence of alcohol and/or any drug? If “yes”, specify ”date(s) of conviction(s) (month/day/year) 7. Have you had any application for life, accidental death and dismemberment or disability insurance withdrawn rated modified or issued other than as applied for? Indicate reason
declined
postponed
8. Are you now receiving or applying for any disability benefits, including workers’ compensation? 9. Have you been Hospitalized as defined below (not including well-baby delivery) in the past 90 days? Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis. 10. Have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC) or the Human Immunodeficiency Virus (HIV) infection? 11. Have you ever been diagnosed, treated or given medical advice by a physician or other health care provider for: a. cardiac or cardiovascular disorder? Indicate type b. stroke or circulatory disorder? Indicate type c. high blood pressure? d. cancer, Hodgkin's disease, lymphoma or tumors? Indicate type e. anemia, leukemia or other blood disorder? Indicate type f. diabetes? Your age at diagnosis? Check if insulin treated g. asthma, COPD, emphysema or other lung disease? Indicate type h. ulcers, stomach, hepatitis or other liver disorder? Indicate type i. colitis, Crohn’s, diverticulitis or other intestinal disorder? Indicate type j. memory loss? Indicate type k. epilepsy, paralysis, seizures, dizziness or other neurological disorder? Specify date of last seizure (month/year) Indicate type l. Epstein-Barr, chronic fatigue syndrome or fibromyalgia? Indicate type m. multiple sclerosis, ALS or muscular dystrophy? Indicate type n. lupus, scleroderma, auto immune disease or connective tissue disorder? o. arthritis? osteoarthritis rheumatoid other/type p. back, neck, knee, spinal, joint or other musculoskeletal disorder? Indicate type q. carpal tunnel syndrome? r. kidney, urinary tract or prostate disorder? Indicate type s. thyroid or other gland disorder? Indicate type t. mental, anxiety, depression, attempted suicide or nervous disorder? Indicate type u. sleep apnea? Indicate type After completing the Personal Physician and Prescription Information on the next page, please provide full details in Section 2 for “yes” answers to questions 5 through 11u.
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Personal Physician Information Personal Physician’s Name: Address (Street, City, State, Zip Code): Date of last visit (MM/DD/YYYY):
/
/
Telephone: (
)
–
Telephone: (
)
–
Telephone: (
)
–
Reason for visit:
Prescription Information Are you currently taking any prescribed medications?
Yes
No
Medication:
If yes, list the medications. Condition/Diagnosis:
Prescribing Physician’s Name: Address (Street, City, State, Zip Code): Medication:
Condition/Diagnosis:
Prescribing Physician’s Name: Address (Street, City, State, Zip Code): Check here if you are attaching another sheet for any additional medications.
SECTION 2 Please provide full details below for each “Yes” answer to questions 5 through 11u in Section 1. If you need more space to provide full details, attach a separate sheet with the information and sign and date it. Delays in processing your application may occur if complete details are not provided. MetLife may contact you for additional or missing information. Check here if you are attaching another sheet. Your name
Employee’s Name
Your Date of Birth
/
/
Question Number
Condition/Diagnosis
Please list any medication prescribed that you did not already identify in the Prescription Information above.
Date of Diagnosis (Month/Year)
Date of Last Treatment (Month/Year)
Type of Treatment
Treating Health Professional Physician’s Name: Date of last visit: Address Street Telephone: ( ) -
Reason for visit: City
State
Zip Code
Question Number
Condition/Diagnosis
Please list any medication prescribed that you did not already identify in the Prescription Information above.
Date of Diagnosis (Month/Year)
Date of Last Treatment (Month/Year)
Type of Treatment
Treating Health Professional Physician’s Name: Date of last visit: Address Street Telephone: ( ) -
86
Reason for visit: City
State
Zip Code
Question Number
Condition/Diagnosis
Please list any medication prescribed that you did not already identify in the Prescription Information above.
Date of Diagnosis (Month/Year)
Date of Last Treatment (Month/Year)
Type of Treatment
Treating Health Professional Physicianâ&#x20AC;&#x2122;s Name: Date of last visit: Address Street Telephone: ( ) -
Reason for visit: City
State
Zip Code
GEF09-1 HEA
FRAUD WARNINGS Before signing this Statement of Health form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued. Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties. New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law. Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
87
DECLARATIONS AND SIGNATURES By signing below, I acknowledge: 1. I have read this Statement of Health form and declare that all information I have given, including any health information, is true and complete to the best of my knowledge and belief. I understand that this information will be used by MetLife to determine insurability. 2. I have read the applicable Fraud Warning(s) provided in this Statement of Health form. Sign Here
Signature of Proposed Insured
Print Name
Date Signed (MM/DD/YYYY)
If a child proposed for insurance is age 18 or over, the child must sign this Statement of Health. If the child is under age 18, a Personal Representative for the child must sign, and indicate the legal relationship between the Personal Representative and the proposed insured. A Personal Representative for the child is a person who has the right to control the childâ&#x20AC;&#x2122;s health care, usually a parent, legal guardian, or a person appointed by a court. Sign Here
Signature of Personal Representative Relationship of Personal Representative
88
Print Name
Date Signed (MM/DD/YYYY)
89
TEXAS LIFE
Permanent Life
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.
YOUR BENEFITS PACKAGE
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 90 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Permanent Life Permanent Life Insurance Coverage An ideal complement to any group term and optional term life insurance your employer might provide, PURELIFE-plus is the life insurance you keep, even when you change jobs or retire. Its high death benefit and long guarantees provide peace of mind for you and your family.
DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.
PURELIFE Features: • •
• • • • • •
It can be an ideal complement to group term and any optional term life insurance your employer might provide. Unlike group and optional term, this policy has a death benefit guaranteed to age 121, as long as you pay the necessary premiums, even when you retire or change jobs. Even if group or optional term is portable, it typically rises in cost and reduces in benefit at retirement. This policy is available to you, your spouse, your minor children, even your minor grandchildren. Premiums are payable through the convenience of payroll deduction. You select the coverage amount and / or premium that best meets your needs. The application process is quick and simple. You can apply for coverage based on your answers to just three work- and health- related Express Issue underwriting questions. This policy offers a significant death benefit at an affordable premium.
Who is eligible? Employees and their spouses, minor children, even your minor grandchildren are eligible to apply for coverage.
How do I enroll? Buying life insurance is a personal decision, and as such, you will have the opportunity to consult with an enrollment representative. Should you decide to apply for coverage, the enrollment representative will guide you through the application process. Our contingent guaranteed issue allows you to apply for generous amounts of coverage by answering just 3 work- and health- related questions.
Who is Texas Life? Texas Life was founded in 1901 and is the oldest life insurance company domiciled in Texas. We are admitted in 49 states and the District of Columbia. We operate out of our home office in Waco, TX. Our Vision is to be known and respected as the leading provider of voluntary permanent life insurance to employees and their families, through their employers, with policies that are easy to sell and buy. 91
Permanent Life High Death Benefit With one of the highest death benefits available at the worksite, PURELIFE-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.
Minimal Cash Value Designed to provide a high death benefit, PURELIFE-plus does not compete with the cash accumulation in your employersponsored retirement plans.
Long Guarantees Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up).
Refund of Premium Unique in the marketplace, PURELIFE-plus offers you a refund of 10 yearsâ&#x20AC;&#x2122; premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)
Accelerated Death Benefit Rider Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in FL) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.)
Portable Coverage is guaranteed as long as required premiums are paid, even after you retire or terminate employment.
Sample Weekly Ratesâ&#x20AC;&#x201D;Non-Tobacco 25 Years Old 35 Years Old 45 Years Old 55 Years Old
$25,000 $1.97 $2.72 $5.54 $12.35
Face Value (1) $50,000 $3.58 $5.08 $10.74 $24.35
$100,000 $6.81 $9.81 $21.12 $48.35
Guaranteed Age (2) 63 64 74 86
(1) Insurance coverage is subject to evidence of insurability. Suicide and contestable clauses apply. (2) Age to which coverage is guaranteed at Table Premium. After the Guaranteed Period, premiums may go down, stay the same or go up.
92
Permanent Life Minimal Cash Values Buy this policy for its life insurance protection, not its cash value. The primary benefit is life insurance. Payment of the Table Premium produces a small cash value (Benchmark Cash Value).
Permanent Life Insurance Coverage Unlike group term life insurance, PureLife-plus is a personally owned, permanent individual life insurance policy to age 121 that can never be canceled or reduced as long as you pay the necessary premiums, even if your health changes.
Guaranteed Period Continuous, timely, and uninterrupted payment of the Table Premium guarantees coverage for the Guaranteed Period stated in the policy. Texas Life (We) cannot legally predict the premium required to continue coverage after the Guaranteed Period. It may be lower, the same, or higher than the Table Premium. However, if the premium to continue coverage is ever higher, We guarantee a limited right to a partial refund of premium.
Guaranteed Limited Right to Partial Refund of Premium If a premium higher than the Table Premium is ever required to continue coverage after the Guaranteed Period, you have the choice to: (a) pay the higher premium(s) required to continue coverage; or, (b) surrender the policy and receive a partial refund of premium equal to 120 times the minimum monthly premium due at issue (10 years worth of Table Premium). You are eligible for this refund if the actual cash value equals or exceeds the Benchmark Cash Value and you have taken no prior partial surrenders. Conditions apply.
Accelerated Death Benefit For no added premium, the policy includes an Accelerated Death Benefit Due to Terminal Illness Rider (Form ULABR-07).1 (“Terminal Condition” in PA.) If the insured becomes terminally ill (or has a terminal condition in PA or a qualifying event in a state with ICC in the policy form number) you may elect to claim an accelerated benefit while the insured is still alive in lieu of the insurance proceeds payable at death. In most states the single sum benefit is 92% (84% in IL) of the insurance proceeds. There is also an administrative fee of $150 ($100 in FL).This is not a long-term care benefit. Terminal Illness (or Condition) is an injury or sickness diagnosed and certified by a qualifying physician that, despite appropriate medical care, is reasonably expected to result in death within 12 months (24 months in IL). We can, at our expense, request the opinion of a physician We choose. A 90day exclusion period applies unless the terminal illness results from accidental bodily injury (30 days in CT, IL, LA, MD, UT; 0 days in OR, PA, SC) Other conditions and limitations apply. Pay premiums faithfully. The rider terminates if the policy ever lapses for non-payment of premium, even if the policy is later reinstated. The right to accelerate benefits under this rider does not extend to any Child Term Life Insurance Rider. However, if the accelerated benefit is paid, the Child Rider
becomes paid-up term insurance to each insured child’s age 25. Payment of the Accelerated Death Benefit terminates the policy and all optional benefits/riders without further value.
Child Term Life Insurance Rider In lieu of an individual policy on each child, if the primary insured is age 59 or less you may apply for a Child Term Life Insurance Rider for $10,000. It insures the primary insured’s children and stepchildren who are ages 15 days through age 18 at the time of application. Children thereafter born to or adopted by the primary insured are covered 15 days after birth. Coverage continues to age 25. Coverage terminates at the primary insured’s age 65. Coverage on a step-child ceases upon the primary insured’s divorce from the step-child’s natural or adoptive parent. If the primary insured dies, coverage is paid-up to the earlier of the insured child’s age 25 or the Contract Anniversary Date on which the primary insured’s Attained Age would have been 65. (ULCL-CIR-07)
Important Notice The insurance proceeds, cash values, and loan values will all be reduced to zero and will no longer be payable if Texas Life pays the Accelerated Death Benefit. The benefit under this rider is intended to qualify for favorable income tax treatment under the Internal Revenue Code of 1986. If the benefit qualifies for such favorable tax treatment, it will be excludable from your income and not subject to federal income taxation. Receipt of the benefit may affect your, your spouse’s or your family’s eligibility for Medicaid, Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance programs. Tax and public benefit laws relating to acceleration of life insurance benefits are complex. You should consult a qualified tax or legal advisor or social services agency to determine how receipt of such payment will affect you and your family. Neither Texas Life nor its agents are authorized to give tax or legal advice.
Interim Insurance Interim insurance will be in force on the application date if these conditions are met: (1) the insurance is purchased through automatic deduction; (2) the deduction authorization is signed; and, (3) the proposed insured is insurable at standard rates under our rules and usual practice. Interim insurance remains in effect until the earlier of: (a) the Policy Date; (b) the date we decline the application; (c) the date We notify the applicant that s/he is ineligible for interim insurance; or, (d) the 180th day after the application date. In Kansas, clauses (3) and (d) do not apply, and clauses (b) and (c) apply only when we refund all premiums. This is a summary only. Policy provisions prevail. This information is not a contract or an offer to contract. Policy Form PRFNG-NI-10 Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 93
CHUBB YOUR BENEFITS PACKAGE
Accident
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-soserious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.
2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or
usually live 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 94 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Accident No one plans on getting injured… but just in case. we've got you covered.
Exclusions & Limitations
Initial Eligibility
Monthly Premiums
GOLD
DIAMOND
Employee • Actively employed working at least 10 hours per week • Ages 18 and up Spouse • Ages 18 and up Dependent children/grandchildren • Ages to 26 • No student status required • Coverage will continue for incapacitated dependent children regardless of age.
Employee Only
$9.40
$16.48
Employee + Spouse
$17.16
$30.12
Employee + Child(ren)
$19.32
$33.64
Family
$27.08
$47.28
This is Accident-Only Insurance. No benefits will be paid for services rendered by a member of Chubb Accident Benefits include the Immediate Family of a Covered Person. First Accident No benefits will be payable for sickness or infection including Pays you $100 soon after you report your first claim for covered physical or mental condition that is not caused solely by or as a benefits! If you get injured, we can begin processing your claim direct result of a Covered Accident. No benefits will be paid for right over the phone so you can get cash fast. an injury that is caused by, contributed to, or occurs as a result Sports Package of a covered person's: Your benefits increase 25%, up to $1,000 per person per year, Being intoxicated, or under the influence of alcohol or any narfor injuries resulting from participating in organized sports! cotic or other prescription drug unless administered on the Playing sports can lead to injuries and unwelcome expenses. advice of a Physician and taken according to the Physician's We'll increase your benefits to help pay those expenses instructions (the term "intoxicated" means the minimum blood Rehabilitation Package alcohol level required to be considered operating an automoWe pay cash benefits for Admission, Daily Confinement and bile under the influence of alcohol in the jurisdiction in which Recovery! Whether you are released to a Rehabilitation Center the accident occurred); following a hospital stay or you recover at home, we pay a daily Participating in an illegal activity or attempting to commit or recovery benefit to help with your transition. actually committing a felony ("felony" is as defined by the law of the jurisdiction in which the activity takes place); Features Committing or attempting to commit suicide or intentionally Date of Application Coverage injuring himself or herself; Coverage becomes effective as soon as your application is signed, you have authorized payment and Having dental treatment, except for such care or treatment due to injury to sound natural teeth within twelve (12) months of the Initial Eligibility requirements are met. the Covered Accident; Guaranteed Issue Being exposed to war or any act of war, declared or undeclared, No medical history is required for coverage to be issued. or serving in any of the armed forces or units auxiliary thereto; Guaranteed Renewable or Your coverage cannot be cancelled as long as your premiums Participation in any contest using any type of motorized vehicle. are paid as due. No benefits will be paid for an injury incurred while working for Fully Portable pay or profit. You can keep your coverage even if you change jobs or retire. HSA Compatible
95
TEXAS LEGAL YOUR BENEFITS PACKAGE
Legal Services
About this Benefit Having an affordable, qualified lawyer on your side can be an invaluable asset. Legal plans provide valuable benefits that cover the most common legal needs you may encounter - like creating a standard will, living will, healthcare power of attorney or buying a home. This plan also provides access to quality law firms for advice, consultation and representation. Benefit is not payroll deducted. To enroll, click LEGAL SERVICES on the Fort Worth ISD benefits portal, and select the QUICK LINK that says Enroll Now.
$1,500 Is the average cost of a basic will and estate planning package. The average yearly premium paid by Texas Legal Members is only $300.
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 96 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Legal Services Save Money and Protect Your Family with Legal Insurance From Texas Legal Legal insurance from Texas Legal lets you save money on legal services that everyone needs, such as estate planning, while protecting you from serious legal challenges that can come with life’s unknowns, including family, civil, consumer, and criminal issues. Texas Legal is a non-profit founded by the State Legislature of Texas over 40 years ago. Our charter is simple - protect everyday Texans from financial hardship that can come with legal challenges. Available only to Texans, we offer the most comprehensive legal insurance plan on the market. As a member of Texas Legal, you can get high-quality legal help without the high price tag.
Texas Legal Membership Advantages As a Member, you are joining thousands of Texans that benefit from legal coverage made available by Texas Legal. Our plans offer freedom of choice to choose an attorney for legal services when you need it the most. And when you choose a Participating Attorney, we will pay the attorney directly, with no copays or deductibles. We’ve been helping Texans like you for over 40 years!
What’s Covered? From life events to unexpected events, Texas Legal has you covered. A legal benefits plan provided by Texas Legal is like homeowners insurance – you may never have to use the full array of benefits, but comprehensive coverage is available in case the unexpected happens.
How Texas Legal Works • •
• •
•
Become a Member Choose a plan and pay an affordable monthly premium. Find an Attorney Whenever you need legal help, we’ll help you find a Texas Legal attorney close to you who can assist with your legal issue. Meet with Your Attorney You choose which attorney you want to work with and meet with them to resolve your legal problem. Problem Solved! Whether it’s writing a will, declaring bankruptcy or defending yourself in small claims court, your attorney will provide you with professional, helpful service. Attorney Fees Paid Your attorney bills Texas Legal for their time and we pay them directly. No deductibles or co-pays!
Frequently Asked Questions Do you provide attorney recommendations? Referral services are highly regulated in Texas, which prohibits us from being able to recommend any particular attorney. You can locate a Texas Legal Participating Attorney by using our Attorney Finder at www.TexasLegal.org. What cost can I expect when I meet with an attorney? Your policy will pay for the attorney’s time to work on your legal matter up to certain limitations. You will not be responsible for any copays or deductibles. Please refer to the Certificate of Coverage for details. Please note, you may be responsible for any incidentals such as court costs, filing fees, copy fees, postage fees, and/or travel costs.
What about non-covered legal matters? Can I still use a Texas Legal Participating Attorney? Yes. If the legal matter is not covered, you may still use a Texas Legal Participating Attorney. However, the attorney will provide you a written contract for services provided and may bill you at a 25% discounted rate of their usual and customary rates. When are my benefits available? Do any benefits have waiting periods? Most benefits are available the first date of your policy. Divorce, modification, enforcement, or establishment of a family court order all have a six-month waiting period. For the Preferred Plan, bankruptcy has a 90-day waiting period. Do you cover pre-existing matters? No. You must be a member of Texas Legal at the time the legal matter occurs. Are all benefits available to each member of my family? Most benefits are available to each family member listed on your policy. However, under the Select Plan, the following are only available to the Named Policyholder: Divorce, Modification, Enforcement, or Establishment of a family court order. Under the Preferred Plan, the following are only available to the Named Policyholder: Residential Real Estate Transactions, Family Immigration Assistance, Identity Theft Monitoring, Divorce, Modification, Enforcement, or Establishment of a family court order. Please note: Once you or your dependent uses a benefit, you cannot use that same benefit again until your plan year renews. Can I use this plan for my business? No. Texas Legal benefit plans are only available for personal or individual legal matters, not for business-related matters. Can I use my plan outside of Texas? Texas Legal does have out-of-network benefits when using a non-participating attorney. Contact us for more information. 97
Legal Services Are you a discount or a referral program? No. Texas Legal operates much like an insurance company. The Participating Attorney you work with will bill Texas Legal for covered legal matters instead of you. How do I get in-office services or court representation? • Confirm your legal matter is covered through your Texas Legal benefits plan. • Choose an attorney via the online Attorney Finder. • Call the attorney’s office and make an appointment. • Let the attorney know you are a member of Texas Legal.
• • • • •
Loan Agreements Real Estate Social Security/Disability Tax Law Financial Counseling
CRIMINAL LAW
Texas Legal membership offers benefits across most areas of law, including:
Criminal law covers a range of activities that vary in severity. Typical issues include matters of constitutional law, juvenile crimes, felonies, and more. Areas include: • DWI/DUI (Defense) • Expunge/Seal Records • Felony (Defense) • Habeas Corpus • Insanity/Infirmity (Defense) • Jail Release • Juvenile Court (Defense) • License Suspension - Revocation (Defense) • Misdemeanor (Defense) • Public Intoxication • Traffic Tickets
CONSUMER LAW
ESTATE PLANNING
What if I just need quick advice? The Legal Access Line may be your best option. You can call and speak with an attorney directly.
Consumer law covers issues like breach of contract, as well as laws pertaining to common issues of consumer fraud. Areas include: • Civil Action (Defense) • Consumer Protection • Contracts • Creditors Rights & Collections • Identity Theft Restoration • Identity Theft Monitoring
FAMILY LAW Family law encompasses matters such as adoption, divorce, custody, and child support. Areas include: • Adoption • Divorce • Establish a Family Court Order (Child Support, Custody, Visitation) • Guardianship • LGBT-specific Family Law • Modify/Enforce Family Court Order (Child Support, Custody, Visitation) • Prenuptial or Postnuptial Agreements • Name Change • Family Immigration Assistance • Protective Orders • Grandparents’ Rights
FINANCIAL LAW Financial law pertains to personal money issues. Areas include: • Chapter 7 Bankruptcy • Chapter 13 Bankruptcy • Foreclosures 98
Estate planning is primarily focused on inheritance planning, but also pertains to charitable planning, incapacity planning, and special needs planning. Areas include: • Powers of Attorney • Probate • Trusts • Wills/Codicils
MISCELLANEOUS There’s a wide range of legal issues that don’t fall into a specific legal category but are common, such as: • Document Preparation • Employment Law (limited to Independent Policies only) • Tenant Rights • Mediation • Medicaid/Medicare • Veteran's Benefits • Consultation • Legal Access Telephone Assistance
Go online to www.TexasLegal.org and use our Attorney Finder to choose a trusted lawyer from our network of Participating Attorneys. Texas Legal 1-800-252-9346 members@texaslegal.org www.TexasLegal.org
7500 Rialto Boulevard Building One, Suite 120 Austin, Texas 78735
Legal Services Choose the Texas Legal Plan that Best Meets Your Needs: Coverages*
Select Plan
Preferred Plan
$10/$15 $100/$150 ✔
$20/$30 $195/$290 ✔
AllClear ID® Identity Theft Monitoring
✔
✔
AllClear ID® Identity Theft Restoration Family Law Divorce -OR- Modification/Establishment or Enforcements Bankruptcy Chapter 7 -OR- Chapter 13 Traffic Tickets
✔
✔
Monthly Annually Estate Planning
10 Hours Covered
✔
25% Discount
✔
25% Discount
✔
—
✔
Family Immigration Assistance
25% Discount
✔
Prenuptial or Postnuptial Agreement
25% Discount
✔
Defense of Misdemeanor Charge
25% Discount
✔
Defense of DWI/DUI
25% Discount
✔
Adoption
25% Discount
✔
8 Hours Covered
✔
Defense of Insanity or Infirmity
25% Discount
✔
Defense of Juvenile/Children's Court
25% Discount
✔
Habeas Corpus
25% Discount
✔
Defense of Felony Charge
25% Discount
✔
Defense of Driving Privileges General Legal Services Consumer Protection
25% Discount 2 Hours Covered Consultations & Negotiations Only
✔ 6 Hours Covered ✔
Uncontested Name Change Attorney Consultation Probate Proceeding
✔ 2 Consultations Covered 25% Discount
✔ 4 Consultations Covered ✔
Residential Real Estate Transaction
25% Discount
✔
Expunction & Order of Nondisclosure
25% Discount
✔
Public Intoxication
25% Discount
✔
Guardianship of Adult or Minor
25% Discount
✔
Protective Order
25% Discount
✔
✔
✔
Financial Counseling
Defense of Civil Action
Legal Access Services
*Limitations and exclusions apply. This information is for illustrative purposes only and is not a contract. Benefits may be subject to limitations and exclusions. For terms, benefits or exclusions, please see plan documents. 99
FORT WORTH ISD
January Savings Plan
About this Benefit The January Savings Plan provided by your employer is a way to set aside funds from your paycheck to offset unexpected holiday costs. During your open enrollment, you can choose a monthly amount to be deducted from your pay check on a regular basis through the scheduled date.
YOUR YOUR BENEFITS BENEFITS PACKAGE PACKAGE
Tips for Saving Money
• • • • • •
Save your loose change. Keep track of your spending. Never purchase expensive items on impulse. Create a budget. Aim for short-term savings goals Save money by buying items online, in bulk.
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 100 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
January Savings Plan
Voluntary enrollment in the January Savings Plan will only be allowed during Benefits Open Enrollment. No interest will be earned on the deduction amount. Deductions will be taken each payday as shown below:
Monthly Dates
Semi-Monthly Dates
September 27, 2019
September 13, 2019
October 28, 2019
September 30, 2019
November 22, 2019
October 15, 2019
December 19, 2019
October 31, 2019 November 15, 2019 November 27, 2019 December 13, 2019
The minimum monthly deduction is $10.00. If a semi-monthly employee selects $10.00 monthly, $5.00 will be taken each pay period marked in the table above. If a monthly employee selects $10.00 monthly, $10.00 will be taken each pay period marked in the table above. Disbursement of the total amount deducted through December will be direct deposited on January 10, 2020. There will be NO early disbursements of funds. Funds in this account will NOT incur interest.
101
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 102 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
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.
BENEFIT
EMERGENT PLUS $14/mo.
PLATINUM $39/mo.
Emergent Ground Transportation
U.S./Canada
U.S./Canada
Emergent Air Transportation
U.S./Canada
U.S./Canada
Non-Emergent Air Transportation
U.S./Canada
Worldwide
“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
Repatriation
U.S./Canada
Worldwide
MASA MTS for Employees Ensures...
Visitor Transportation
BCA*
Minor Children/ Grandchildren Return
BCA*
Vehicle Return
BCA*
Pet Return
BCA*
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.
• • • • • •
NO health questions NO age limits NO claim forms NO deductibles NO provider network limitations NO dollar limits on emergency transport costs
Escort Transportation
Worldwide
Mortal Remains Transportation
Worldwide
Organ Retrieval
U.S./Canada
Organ Recipient Transportation
U.S./Canada
*Basic Coverage Area (BCA) includes U.S., Canada, Mexico, and Caribbean (excluding Cuba)
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Platinum Membership Benefits Emergency Air Medical Transportation
Emergency Ground Transportation
Non-Emergent Air Transportation
Should a member suffer serious life or limb threatening emergency that requires immediate transport by fixed wing or helicopter air ambulance of that member to the nearest most appropriate medical facility capable of providing required emergency medical treatments, also referred to as “golden hour transports”, MASA MTS will cover the out-ofpocket expenses resulting from that transport. (U.S. and Canada Only) Should a member suffer a life or limb emergency requiring emergent ground transport from the site of serious illness or injury, or from a transferring medical facility that is unable to provide services required, to the nearest most appropriate medical facility capable of attending to the member’s medical needs MASA MTS will cover the out-of-pocket expenses resulting from that transport. (U.S. and Canada Only) Should a member suffer a serious illness or injury resulting in hospitalization and if the member is in need of specialized treatment not available locally but such transportation is not immediately needed for life or limb saving treatment and such transportation can be arranged by MASA, then MASA MTS will coordinate transport to the nearest appropriate medical facility capable of providing such specialized treatment. (Worldwide Coverage)
Organ Retrieval**
MASA MTS will provide air transportation of an organ to be used in an organ transplant. (U.S. Only)
Organ Recipient Transportation**
MASA MTS will fly a member to the commercial airport nearest the medical facility where an organ transplant is scheduled to happen. (U.S. Only)
Recuperation / Repatriation
If a member is hospitalized while away from home, MASA MTS will fly them back to a hospital closer to home to recuperate in familiar surroundings. (Worldwide Coverage)
Return Transportation
MASA MTS will arrange transport on a commercial carrier to a commercial airport closest to member’s residence after being discharged from a hospitalization of at least 24 hours. (Worldwide Coverage)
Escort Transportation
If a member requires emergency air transport, MASA MTS will fly the member's spouse, family member or friend to accompany them in the air. (Worldwide Coverage)
If a member is hospitalized while away from his/her home for more than 7 days, the member may select a family member to visit them during confinement. MASA MTS will provide Visitor Transport round trip, common carrier air transportation for the person selected. (Basic Coverage Area Only*) When minor children or grandchildren are left unattended as a result of a member using MASA MTS air ambulance service, MASA MTS will provide one-way common carrier air Minor Children / Grandchildren Return transport for return of the children to the commercial airport nearest the place of residence of the children. (Basic Coverage Only*) MASA MTS will return vehicles such as cars, vans, RVs or trucks owned or rented by the member when illness, injury or death requires use of the air ambulance services provided Vehicle Return by MASA MTS. The vehicle will be carried to the member's place of residence or rental vehicles will be returned to the nearest rental company office or agent. (Basic Coverage Area Only*) In the event a member dies while away from his/her place of residence, MASA Assist will Mortal Remains return his/her remains to the commercial airport nearest his/her residence. (Worldwide Transport Coverage)
Pet Return
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MASA MTS will return the Member’s dog, cat or smaller animal, should the Member be flown to a hospital near their residence on an air ambulance arranged by the MASA MTS. (Basic Coverage Area Only*)
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