PORT NECHES-GROVES ISD
BENEFIT GUIDE
EFFECTIVE: 09/01/2019 - 8/31/2020 WWW.MYBENEFITSHUB.COM/PORTNECHESGROVESISD 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) TRS-ActiveCare HSA Bank Health Savings Account (HSA) Aetna Hospital Indemnity MDLIVE Telehealth Cigna Dental Superior Vision APL Cancer Unum Long Term Disability Cigna Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider ID Watchdog Identity Theft MASA Emergency Medical Transportation NBS Flexible Spending Account (FSA) 2
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FLIP TO... PG. 4
HOW TO ENROLL
PG. 6
SUMMARY PAGES
PG. 12
YOUR BENEFITS
11 12-13 14-17 18-23 24-25 26-29 30-31 32-39 40-43 44-47 48-51 52-53 54-55 56-59
Benefit Contact Information PORT NECHES-GROVES ISD BENEFITS
VISION
FAMILY PROTECTION PLAN
Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/ portnechesgrovesisd
Superior Vision (800) 507-3800 www.superiorvision.com
5Star Life Insurance Company (866) 863-9753 www.5starlifeinsurance.com
MEDICAL
CANCER
TELEHEALTH
Aetna (800) 222-9205 www.trsactivecareaetna.com
American Public Life (800) 256-8606 www.ampublic.com
MDLIVE (888) 365-1663 www.consultmdlive.com
HEALTH SAVINGS ACCOUNT
DISABILITY
IDENTITY THEFT
HSA Bank (800) 357-6246 www.hsabank.com
UNUM Claims Info: (800) 583-6908 www.unum.com
IDWatchdog (866) 513-1518 www.idwatchdog.com
DENTAL
LIFE AND AD&D
FLEXIBLE SPENDING & FINANCIAL PLANNING ACCOUNT
Cigna (800) 244-6224 www.cigna.com
Cigna (800) 583-6908 www.cigna.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
HOSPITAL INDEMNITY
EMERGENCY MEDICAL TRANSPORTATION
Aetna (800) 872-3862 www.aetna.com
MASA (800) 423-3226 www.masamts.com 3
MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS PNG” 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 PNG” to 313131 OR SCAN
How to Log In
1 BENEFIT INFO
INTERACTIVE TOOLS
2 3
www.mybenefitshub.com/ portnechesgrovesisd
CLICK LOGIN
ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below:
Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.
ONLINE SUPPORT
If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.
Default Password: Last Name (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.
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Annual Benefit Enrollment
SUMMARY PAGES
Benefit Updates - What’s New: •
Benefit elections will become effective 9/1/2019. Elections requiring evidence of insurability, such as Life Insurance, may have a later effective date, if approved. After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 31 days of event).
•
Aetna remains the carrier for TRS Medical Plans: ActiveCare 1 HD, ActiveCare 2 and ActiveCare Select. All eligible employees, including active, contributing TRS members and employees regularly working 10 hours per week MUST either enroll for coverage or decline coverage in the Benefits HUB. For comprehensive TRS medical information, visit the website, www.trsactivecareaetna.com.
•
A Health Savings Account with HSA Bank is a tax-free savings account available for those employees enrolled in ActiveCare 1 HD. These funds can be used to pay for medical, dental, vision or prescription expenses. The HSA annual contribution maximum is $3,500 for individuals and $7,000 for your family. For individuals who are between 55-65, there is an additional catch-up provision of $1,000 that can be contributed annually.
•
Flexible Spending Account: National Benefit Services is the FSA Administrator for Port Neches Groves ISD. The 2020 FSA contribution limit is $2,700. Remember, you must re-elect a new contribution amount every year to continue to participate. You can manually submit claims prior to receiving your cards. Find the claim form on the benefits website at www.mybenefitshub.com/portnechesgrovesisd. PNGISD offers a $500 rollover provision. Any remaining balance above $500 will be forfeited.
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Hospital Indemnity: This supplemental coverage helps offset out‐of‐pocket costs you experience due to deductibles and out of pocket maximum’s in your employer’s medical plan. Two Low/High Options— Hospital Admission $1,500/$2,500 per insured.
•
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 can include emergency transportation via ground ambulance, air ambulance and helicopter, depending on the plan.
Don’t Forget! • •
Login and complete your benefit enrollment from 07/08/2019 - 08/19/2019 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202. Hours: Monday - Thursday 8am-5:30am, Friday 8am-3pm
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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 your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
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.
For benefit summaries and claim forms, go to your school
Changes are not permitted during the plan year (outside of
district’s benefit website: www.mybenefitshub.com/
annual enrollment) unless a Section 125 qualifying event occurs.
portnechesgrovesisd. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you
•
Changes, additions or drops may be made only during the
need under the Benefits and Forms section.
annual enrollment period without a qualifying event. How can I find a Network Provider?
• Employees must review their personal information and verify that dependents they wish to provide coverage for are
district’s benefit website: www.mybenefitshub.com/
included in the dependent profile. Additionally, you must
portnechesgrovesisd. Click on the benefit plan you need
notify your employer of any discrepancy in personal and/or benefit information.
•
For benefit summaries and claim forms, go to your school
Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
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
New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.
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SUMMARY PAGES
Employee Eligibility Requirements
Dependent Eligibility Requirements
Supplemental Benefits: Eligible employees must work 17.5 or
Dependent Eligibility: You can cover eligible dependent
more regularly scheduled hours each work week.
children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the
Eligible employees must be actively at work on the plan effective
maximum age listed below. Dependents cannot be double
date for new benefits to be effective, meaning you are physically
covered by married spouses within Port Neches-Groves ISD
capable of performing the functions of your job on the first day of
or as both employees and dependents.
work concurrent with the plan effective date. For example, if your 2019 benefits become effective on September 1, 2019, you must be actively-at-work on September 1, 2019 to be eligible for your new benefits.
PLAN
CARRIER
MAXIMUM AGE
Medical
Aetna
To age 26
Dental
Cigna
To age 26
Vision
Superior Vision
To age 26
Life
Cigna
To age 26
Cancer
American Public Life
To age 26
Family Protection Plan
5Star
Issue to age 24, keep to age 100
Telehealth
MDLIVE
To age 26
Identity Theft Protection
IDWatchdog
To age 26
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.
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Helpful Definitions
SUMMARY PAGES
Actively at Work
In-Network
You are performing your regular occupation for the employer
Doctors, hospitals, optometrists, dentists and other providers
on a full-time basis, either at one of the employer’s usual
who have contracted with the plan as a network provider.
places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2019 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.
Out-of-Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.
Plan Year September 1st through August 31st
Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services
Calendar Year January 1st through December 31st
Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.
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(including diagnostic and/or consultation services).
SUMMARY PAGES
HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care taxfree.
Employer Eligibility
A qualified high deductible health plan.
All employers
Contribution Source Account Owner Underlying Insurance Requirement
Employee and/or employer Individual
Employee and/or employer Employer
High deductible health plan
None
Description
Minimum Deductible Maximum Contribution
Permissible Use Of Funds
$1,350 single (2019) $2,700 family (2019) $3,500 single (2019) $7,000 family (2019) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
N/A $2,700 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).
Not permitted
Year-to-year rollover of account balance?
Yes, will roll over to use for subsequent year’s health coverage.
No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
FLIP TO FOR HSA INFORMATION
PG. 14
FLIP TO FOR FSA INFORMATION
PG. 56 11
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 is 12administered 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 3 25% coinsurance after deductible 25% coinsurance (min. $404; max. $80)3 3 50% coinsurance after deductible 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. 13
HSA BANK
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 14 details on covered limitations and exclusions arewww.mybenefitshub.com/portnechesgrovesisd included in the summary plan description located on the Portexpenses, Neches Groves ISD Benefits Website: Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.
What is an HSA? •
• •
A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.
Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.
Examples of Qualified Medical Expenses • • • • • •
Surgery Braces Contact lenses Dentures Eyeglasses Vaccines
For a list of sample expenses, please refer to your benefit website at www.mybenefitshub.com/portnechesgrovesisd
HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com
Using Funds Debit Card • You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements. • You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.
2019 Annual HSA Contribution Limits Individual: $3,500 Family: $7,000 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000. • Health Savings accountholder • Age 55 or older (regardless of when in the year an accountholder turns 55) • Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated) 15
How the HSA Plan Works A Health Savings Account (HSA) is an individually-owned, taxadvantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through selfdirected investment options1.
How an HSA works: •
•
• •
You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well. You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings. Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes). Check balances and account information via HSA Bank’s Internet Banking 24/7.
Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally: • You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B. • You cannot be covered by TriCare. • You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA). • You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse). • You must be covered by the qualified HDHP on the first day of the month. When you open an account, HSA Bank will request certain information to verify your identity and to process your application.
What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2. 16
2019 Annual HSA Contribution Limits Individual = $3,500 Family = $7,000
Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catchup contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.
How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how: • Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible. • HSA funds earn interest and investment earnings are tax free. • When used for IRS-qualified medical expenses, distributions are free from tax.
IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always taxfree. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.
How the HSA Plan Works Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)
Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRSqualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs
Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays
For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081
1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 17
AETNA YOUR BENEFITS PACKAGE
Hospital Indemnity
About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.
The median hospital costs per stay have steadily grown to over $10,500 per day.
$9,600
$10,400
$10,700
2008
2012
2018
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 18 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Hospital Indemnity BENEFIT SUMMARY Port Neches Groves Independent School District 802492 Aetna Hospital Indemnity Insurance plans are underwritten by Aetna Life Insurance Company. Unless otherwise indicated, all benefits and limitations are per covered person. The Aetna Hospital Indemnity Plan is a hospital confinement indemnity plan with other fixed indemnity benefits. THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THESE PLANS ARE A SUPPLEMENT TO HEALTH INSURANCE AND ARE NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. These plans provide limited benefits. They pay fixed dollar benefits for covered services without regard to the health care provider's actual charges. These benefit payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider's bills get paid. These benefits are paid in addition to any other health coverage you may have. THIS IS NOT A MEDICARE SUPPLEMENT (MEDIGAP) PLAN. If you are or will become eligible for Medicare, review the free Guide to Health Insurance for People with Medicare available at www.medicare.gov. This policy, alone, does not meet Massachusetts Minimum Creditable Coverage standards.
Inpatient Stays Covered Benefit
Plan 2
Plan 4
$1,000
$2,000
$100
$200
$200
$400
$100
$200
$100
$200
Substance abuse stay - Daily Pays a daily benefit for each day you have a stay in a hospital or substance abuse treatment facility for the treatment of substance abuse. Maximum 30 days per plan year
$100
$200
Mental disorder stay - Daily Pays a daily benefit for each day you have a stay in a hospital or mental disorder treatment facility for the treatment of mental disorders. Maximum 30 days per plan year
$100
$200
$50
$100
Hospital stay - Admission Provides a lump sum benefit for the initial day of your stay in a hospital. Maximum 1 stay per plan year Hospital stay - Daily Pays a daily benefit, beginning on day two of your stay in a non-ICU room of a hospital. Maximum 30 days per plan year Hospital stay - (ICU) Daily Pays a daily benefit, beginning on day two of your stay in an ICU room of a hospital. Maximum 30 days per plan year Newborn routine care Provides a lump-sum benefit after the birth of your newborn. This will not pay for an outpatient birth. Observation unit Provides a lump sum benefit for the initial day of your stay in an observation unit as the result of an illness or accidental injury. Maximum 1 day per plan year
Rehabilitation unit stay - Daily Pays a benefit each day of your stay in a rehabilitation unit immediately after your hospital stay due to an illness or accidental injury. Maximum 30 days per plan year
Important Note: All daily inpatient stay benefits begin on day two and count toward the plan year maximum.
19
Hospital Indemnity - Rate Sheet Rates shown are based on monthly deductions. Your payroll deductions will be taken after taxes are taken.
Hospital Indemnity Plan You may enroll in one option only.
Plan 2
Cost
Plan 4
Cost
Yourself only
$18.44
Yourself only
$36.89
Yourself & spouse
$38.91
Yourself & spouse
$77.83
Yourself plus child(ren)
$28.40
Yourself plus child(ren)
$56.79
Yourself and family
$45.47
Yourself and family
$90.94
THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THESE ARE A SUPPLEMENT TO HEALTH INSURANCE AND NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. Plans are underwritten by Aetna Life Insurance Company (Aetna). Insurance plans contain exclusions and limitations. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Policies may not be available in all states, and rates and benefits may vary by location. Supplemental health plans provide limited benefits. The benefit payments are not intended to cover the full cost of medical care. Providers are independent contractors and are not agents of Aetna. This material is for information only and is not an offer or invitation to contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. Financial Sanctions Exclusions Clause: If coverage provided by this policy violates or will violate any US economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments or reimburse for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or entity, or a country under sanction by the United States, unless permitted under a valid written Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx. Policy forms issued in Oklahoma and Idaho include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01
20
Hospital Indemnity Portability Your plan includes a Portability option which allows you to keep your existing coverage by making direct payments to the carrier. You may exercise this option, if your employment ceases for any reason. Refer to your Certificate for additional Portability provisions. Waiver of premium If you are in a hospital for more than 30 days in a row, we will waive the premium beginning on the first premium due date that occurs after the 30th day of your stay, through the next 6 months of coverage. During your stay, you must remain employed with the policyholder.
Exclusions and Limitations
Questions and Answers
This plan has exclusions and limitations. Refer to the actual policy and certificate to determine which benefits are not payable. The following is a partial list of services and supplies that are generally not covered. However, the plan may contain exceptions to this list based on state mandates or the plan design purchased. Benefits will not be paid for any stay or other service for an illness or accidental injury related to the following: 1. Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping, parachuting, skydiving 2. Any semi-professional or professional competitive athletic contest, including officiating or coaching, for which you receive any payment 3. Act of war, riot, war 4. Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or not 5. Assault, felony, illegal occupation, or other criminal act 6. Care provided by a spouse, parent, child, sibling or any other household member 7. Cosmetic services and plastic surgery, with certain exceptions 8. Custodial Care 9. Hospice services, except as specifically provided in the Benefits under your plan section of the certificate 10. Self-harm, suicide, except when resulting from a diagnosed disorder 11. Violating any cellular device use laws of the state in which the accident occurred, while operating a motor vehicle 12. Care or services received outside the United States or its territories 13. Education, training or retraining services or testing 14. Accidental injury sustained while intoxicated or under the influence of any drug intoxicant 15. Exams except as specifically provided in the Benefits under your plan section of the certificate 16. Dental and orthodontic care and treatment 17. Family planning services 18. Any care, prescription drugs, and medicines related to infertility 19. Nutritional supplements, including but not limited to: food items, infant formulas, vitamins 20. Outpatient cognitive rehabilitation, physical therapy, occupational therapy, or speech therapy for any reason 21. Vision-related care
Do I have to be actively at work to enroll in coverage? Yes, you must be actively at work in order to enroll and for coverage to take effect. You are actively at work if you are working, or are available to work, and meet the criteria set by your employer to be eligible to enroll. Can I enroll in the Aetna Hospital Indemnity plan even though I have a Health Savings Account (HSA)? Yes, you can still enroll in the Aetna Hospital Indemnity plan if you have a Health Savings Account. What is considered a hospital stay? A stay is a period during which you are admitted as an inpatient; and are confined in a hospital or non-hospital residential facility; and are charged for room, board and general nursing services. A stay does not include time in the hospital because of custodial or personal needs that do not require medical skills or training. A stay specifically excludes time in the hospital for observation or in the emergency room unless this leads to a stay. If I lose my employment, can I take the Hospital Indemnity Plan with me? Yes, you are able to continue coverage under the Portability provision. You will need to pay premiums directly to Aetna. How do I file a claim? Go to myaetnasupplemental.com and either “Log In” or “Register”, depending on if you’ve set up your account. Click the “Create a new claim” button and answer a few quick questions. You can even save your claim to finish later. You can also print/ mail in form(s) to: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512- 4079, or you can ask us to mail you a printed form. What should I do in case of an emergency? In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. What if I don’t understand something I’ve read here, or have more questions? Please call us. We want you to understand these benefits before you decide to enroll. You may reach one of our Customer Service representatives Monday through Friday, 8 a.m. to 6 p.m., by calling 1-800-607-3366. We’re here to answer questions before and after you enroll 21
Hospital Indemnity If you’d like a copy of our privacy notice, call 1-800-607-3366 or visit us at www.aetna.com. IN ORDER FOR THE HOSPITAL INDEMNITY BENEFITS TO BE If you require language assistance, please call Member Services at PAYABLE, THE INITIAL DAY OF YOUR STAY AND OTHER SERVICES 1-800-607-3366 and an Aetna representative will connect you MUST BE ON OR AFTER YOUR EFFECTIVE DATE OF COVERAGE. with an interpreter. If you’re deaf or hard of hearing, use your Complaints and appeals Please tell us if you are not satisfied with a response you received TTY and dial 711 for the Telecommunications Relay Service. Once from us or with how we do business. Call Member Services to file connected, please enter or provide the Aetna telephone number you’re calling. a verbal complaint or to ask for the address to mail a written Si usted necesita asistencia lingüística, por favor llame al Servicios complaint. You can also e-mail Member Services through the al Miembro a 1-800-607-3366 y un representante de Aetna le secure member website. If you’re not satisfied after talking to a conectará con un intérprete. Si usted es sordo o tiene problemas Member Services representative, you can ask us to send your de audición, use su TTY y marcar 711 para el Servicio de issue to the appropriate department. If you don’t agree with a denied claim, you can file an appeal. To Retransmisión de Telecomunicaciones (TRS). Una vez conectado, file an appeal, follow the directions in the letter or explanation of por favor entrar o proporcionar el número de teléfono de Aetna benefits statement that explains that your claim was denied. The que está llamando. letter also tells you what we need from you and how soon we will ATTENTION MASSACHUSETTS RESIDENTS: As of January 1, 2009, respond. the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years of age and older, We protect your privacy must have health coverage that meets the Minimum Creditable We consider personal information to be private. Our policies Coverage standards set by the Commonwealth Health Insurance protect your personal information from unlawful use. By Connector, unless waived from the health insurance requirement “personal information,” we mean information that can identify you as a person, as well as your financial and health information. based on affordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL (1-877-623Personal information does not include what is available to the 6765) or visit the Connector website public. For example, anyone can access information about what (www.mahealthconnector.org) . THIS POLICY, ALONE, DOES NOT the plan covers. It also does not include reports that do not MEET MINIMUM CREDITABLE COVERAGE STANDARDS. If you identify you. When necessary for your care or treatment, the operation of our have questions about this notice, you may contact the Division of Insurance by calling 1-617-521-7794 or visiting its website at health plans or other related activities, we use personal www.mass.gov/doi. information within our company, share it with our affiliates and may disclose it to: your doctors, dentists, pharmacies, hospitals Financial Sanctions Exclusions Clause and other caregivers, other insurers, vendors, government If coverage provided by this policy violates or will violate any US departments and third-party administrators (TPAs). economic or trade sanctions, the coverage is immediately We obtain information from many different sources — considered invalid. For example, Aetna companies cannot make particularly you, your employer or benefits plan sponsor if payments or reimburse for health care or other claims or services applicable, other insurers, health maintenance organizations or if it violates a financial sanction regulation. This includes sanctions TPAs, and health care providers. related to a blocked person or entity, or a country under sanction These parties are required to keep your information private as by the United States, unless permitted under a valid written required by law. Some of the ways in which we may use your information include: Paying claims, making decisions about what Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit http://www.treasury.gov/resourcethe plan covers, coordination of payments with other insurers, center/sanctions/Pages/default.aspx. quality assessment, activities to improve our plans and audits. Plans are underwritten by Aetna Life Insurance Company (Aetna). We consider these activities key for the operation of our plans. This material is for information only and is not an offer or When allowed by law, we use and disclose your personal invitation to contract. Information is believed to be accurate as of information in the ways explained above without your permission. Our privacy notice includes a complete explanation of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. the ways we use and disclose your information. It also explains Hospital Indemnity Policy forms issued in Idaho, Oklahoma and when we need your permission to use or disclose your Missouri include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp information. 01. We are required to give you access to your information. If you think there is something wrong or missing in your personal information, you can ask that it be changed. We must complete your request within a reasonable amount of time. If we don’t agree with the change, you can file an appeal.
Important information about your benefits
22
Non-Discrimination Notice Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call 1-888-772-9682. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 1-800-648-7817, TTY: 711, Fax: 859-425-3379, CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Availability of Language Assistance Services TTY: 711 For language assistance in your language call 1-888-772-9682 at no cost. (English)
Para obtener asistencia lingüística en su idioma, llame sin cargo al 1-888-772-9682. (Spanish) 欲取得以您的語言提供的語言協助，請撥打1-888-772-9682，無需付費。(Chinese) Pour une assistance linguistique dans votre langue, appeler le 1-888-772-9682 sans frais. (French) Para sa tulong sa inyong wika, tumawag sa 1-888-772-9682 nang walang bayad. (Tagalog) Hilfe oder Informationen in deutscher Sprache erhalten Sie kostenlos unter der Nummer 1-888-772-9682. (German) ﺪﺎﻧﻤﺠﻤ ةﺪﺟﻗﺮ ةﻠﻋﻠ ﺎﺼﺗﻤا ةﺪﺟﺮﻤةﺪﻋﻮﻐﻠﺑ ﺔﻋﻮﻐﻠ ا ةﺪﻋﺎﺴﻤﻠﻟ.1-888-772-9682 (Arabic) Pou jwenn asistans nan lang pa w, rele nimewo 1-888-772-9682 gratis. (French Creole)
Per ricevere assistenza nella sua lingua, può chiamare gratuitamente il numero 1-888-772-9682. (Italian) 日本語で援助をご希望の方は 1-888-772-9682 (フリーダイアル) までお電話ください。(Japanese)
본인의 언어로 통역 서비스를 받고 싶으시면 비용 부담 없이 1-888-772-9682번으로 전화해 주십시오. (Korean) ه ﺎﺎﻤ ﺔﻤ ﺎﺎﻤ ﺔﻤز ﺎﻤﻠﯽ ﺔﻤ ةا ةاﺔﺟ1-888-772-9682 ﺔﯾ ﺟﻠﻟ ﺼﺎﻤةا ﻠ ﻤ ا ﭻ ھ اﺔﻟ. (Persian) Aby uzyskać pomoc w swoim języku, zadzwoń bezpłatnie pod numer 1-888-772-9682. (Polish) Para obter assistência no seu idioma, ligue gratuitamente para o 1-888-772-9682. (Portuguese) Чтобы получить помощь c переводом на ваш язык, позвоните по бесплатному номеру 1-888-772-9682. (Russian) Để được hỗ trợ ngôn ngữ bằng ngôn ngữ của bạn, hãy gọi miễn phí đến số 1-888-772-9682. (Vietnamese)
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MDLIVE
Telehealth
About this Benefit Telehealth provides 24/7/365 access to boardcertified doctors via telephone consultations that can diagnose, recommend treatment and prescribe medication. Whether you are at home, traveling or at work, Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.
YOUR BENEFITS PACKAGE
75%
of all doctor, urgent care, and ER visits could be handled safely and effectively via telehealth.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included 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 limitations and exclusions arewww.mybenefitshub.com/portnechesgrovesisd included in the summary plan description located on the Portexpenses, Neches Groves ISD Benefits Website: Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Telehealth When should I use MDLIVE? • If you’re considering the ER or urgent care for a non-emergency medical issue • Your primary care physician is not available • At home, traveling, or at work • 24/7/365, even holidays!
What can be treated? • • • • • • • • •
Allergies Asthma Bronchitis Cold and Flu Ear Infections Joint Aches and Pain Respiratory Infection Sinus Problems And More!
Pediatric Care related to: • • • • • • •
Cold & Flu Constipation Ear Infection Fever Nausea & Vomiting Pink Eye And More!
Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.
How much does it cost? $0 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.
Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp • • • • •
Access to a doctor anywhere: at home, at work, or on the go Choose doctors from one of the nation's largest telehealth networks Available 24/7 by video or phone Private, secure and confidential visits Connect instantly with MDLIVE Assist
Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.
Scan with your smartphone to get the app.
Call us at (888) 365-1663 or visit us at www.consultmdlive.com
Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for 25 abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/terms-of-use/ 010113
CIGNA
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 26 details on covered limitations and exclusions arewww.mybenefitshub.com/portnechesgrovesisd included in the summary plan description located on the Portexpenses, Neches Groves ISD Benefits Website: Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Dental PPO - High Option Benefits Network Plan Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**
Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $1,000
$1,000
$50 per person $150 per family
$50 per person $150 per family
Based on Reduced Contracted Fees
90th percentile of Reasonable and Customary Allowances
Plan Pays You Pay** Plan Pays You Pay** Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Fluoride Application Sealants Space Maintainers Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Denture Repairs Repairs to Bridges, Crowns and Inlays Oral Surgery – Simple Extractions Class III - Major Restorative Care Crowns Denture Relines, Rebases and Adjustments Dentures Bridges Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia Lifetime Maximum $1000 No Deductible Dependent Children to age 19
100%
No Charge
100%
No Charge
80%*
20%*
80%*
20%*
Monthly PPO Premiums Tier
Rate
EE Only
$28.08
EE + Spouse
$66.56
EE + Child(ren)
$79.28
Family Coverage
$109.62
**For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an outof-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.
50%* 50%** 50%* 50%** After After After After deductible deductible deductible deductible
50%
50%**
50%
50%**
Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides: • 100% coverage for certain dental procedures • guidance on behavioral issues related to oral health • discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national 27Cigna Dental PPO network. Dependents/Students up to age 26.
Dental PPO - Low Option Benefits Network Plan Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**
Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $1,000
$1,000
$50 per person $150 per family
$50 per person $150 per family
Based on Reduced Contracted Fees
Based on Maximum Allowable Charge (In-network fee level)
Plan Pays You Pay** Plan Pays You Pay** Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Fluoride Application Sealants Space Maintainers Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Osseous Surgery Periodontal Scaling and Root Planing Oral Surgery – Simple Extractions Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Prosthesis Over Implant Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays
Class IV - Orthodontia
100%
No Charge
100%
No Charge
80%*
20%*
80%*
20%*
Monthly PPO Premiums Tier
Rate
EE Only
$18.34
EE + Spouse
$35.14
EE + Child(ren)
$41.82
Family Coverage
$64.98
**For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an outof-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.
50%* 50%* 50%* 50%* After After After After deductible deductible deductible deductible
Not covered
100% of your dentist’s usual fees
Not covered
100% of your dentist’s usual fees
Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides: • 100% coverage for certain dental procedures • guidance on behavioral issues related to oral health • discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.28 In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Dependents/Students up to age 26.
Dental PPO - High and Low Options Procedure
Exclusions and Limitations
Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Sealants Space Maintainers Prosthesis Over Implant
Two per Plan year Two per Plan year 1 per Plan year for people under 19 Various limits per Plan year depending on specific test Bitewings: 2 per Plan year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to a ge 16 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses
Alternate Benefit
Benefit Exclusions • • • • • • • • • • • • • • • • • • • • • • • • •
Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.
This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD57614 © 2015 Cigna
29
SUPERIOR VISION
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 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 30 details on covered limitations and exclusions arewww.mybenefitshub.com/portnechesgrovesisd included in the summary plan description located on the Portexpenses, Neches Groves ISD Benefits Website: Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Vision - Superior National Network Benefits
In-Network
Out-of-Network
Exam Covered in full Up to $42 retail (ophthalmologist) Exam (optometrist) Covered in full Up to $37 retail Frames $130 retail allowance Up to $68 retail Contact Lens Fitting Covered in full Not covered (standard2) Contact Lens Fitting $50 retail allowance Not covered (specialty2) Contact Lenses3 $100 retail allowance Up to $100 retail
Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive lens upgrade
Covered in full Covered in full Covered in full
Up to $32 retail Up to $46 retail Up to $61 retail
See description4
Up to $61 retail
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.
Monthly Premiums EE Only EE + Spouse EE + Child(ren) EE + Family
$10.31 $20.43 $20.02 $30.45
Co-Pays Exam Materialsâ‚ Contact Lens Fitting (standard & specialty)
$10 $10 $25
Services/Frequency Exam Frame Contact Lens Fitting Lenses Contact Lenses
12 months 12 months 12 months 12 months 12 months
(Based on date of service)
1
Materials co-pay applies to lenses and frames only, not contact lenses See your benefits materials for definitions of standard and specialty contact lens fittings 3 Contact lenses are in lieu of eyeglass lenses and frames benefit 4 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 2
Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary.
Discounts on Covered Materials Frames: Lens options: Progressives:
20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options
The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) plastic lenses.
Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: Lens options, contacts, other prescription materials: Disposable contact lenses:
30% off retail 20% off retail 10% off retail
Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance.
5
Discounts and maximums may vary by lens type. Please check with your provider.
Maximum Member Out-of-Pocket Scratch coat Ultraviolet coat Tints, solid or gradients Anti-reflective coat Polycarbonate High index 1.6 Photochromics
Single Vision $13 $15 $25 $50 $40 $55 $80
Bifocal & Trifocal $13 $15 $25 $50 20% off retail 20% off retail 20% off retail
All allowances are retail; member is responsible for any amount over the allowance, minus available discounts. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.
31
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 32 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
GC12 Limited Benefit Group Cancer Indemnity Insurance
Port Neches Groves ISD
THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Summary of Benefits Benefits
Option 1 Base Plan
Option 2 Base Plan
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 per Calendar Year
$500 per test
$500 per test
Cancer Treatment Benefits
Level 1
Level 4
Radiation Therapy, Chemotherapy or Immunotherapy Maximum per 12-month period
$10,000
$20,000
$50 per treatment
$50 per treatment
Level 1
Level 1
$30 Unit Dollar Amount Maximum $3,000 per operation
[$30 Unit Dollar Amount Maximum $3,000 per operation
25% of amount paid for covered surgery
25% of amount paid for covered surgery
$6,000
$6,000
$600
$600
Prosthesis Surgical Implantation – 1 device per site, per lifetime Non-Surgical (not hair piece) – 1 device per site, per lifetime
$1,000 $100
$1,000 $100
Patient Care Benefits
Level 1
Level 1
$100 $200 $100 $200
$100 $200 $100 $200
Outpatient Facility - Per day surgery is performed
$200
$200
Attending Physician - Per day of Hospital Confinement
$30
$30
Dread Disease Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)
$100 $100
$100 $100
Extended Care Facility Up to the same number of Hospital Confinement Days
$100 per day
$100 per day
Donor
$100 per day
$100 per day
Home Health Care Up to the same number of Hospital Confinement Days
$100 per day
$100 per day
Hospice Care Up to maximum of 365 days per lifetime
$100 per day
$100 per day
$100 $100
$100 $100
Cancer Screening Benefits
Hormone Therapy - Maximum of 12 treatments per Calendar Year Surgical Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime
Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent children Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent children
US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)
APSB-22338(TX) MGM/FBS Port Neches Groves ISD
33
GC12 Limited Benefit Group Cancer Indemnity Insurance Miscellaneous Benefits
Level 1
Level 1
Cancer Treatment Center Evaluation or Consultation - 1 per lifetime
N/A
N/A
Evaluation or Consultation Travel and Lodging - 1 per lifetime
N/A
N/A
$300 per Diagnosis of Cancer $300 per Diagnosis of Cancer
$300 per Diagnosis of Cancer $300 per Diagnosis of Cancer
$150 per Confinement $50 per Prescription
$150 per Confinement $50 per Prescription
$150
$150
Actual coach fare or $.40 per mile
Actual coach fare or $.40 per mile
Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined
$.40 per mile
$.40 per mile
Lodging - up to a maximum of 100 days per Calendar Year
$50 per day
$50 per day
Actual coach fare or $.40 per mile
Actual coach fare or $.40 per mile
$.40 per mile
$.40 per mile
$50 per day
$50 per day
Blood, Plasma and Platelets
$300 per day
$300 per day
Experimental Treatment
Paid in the same manner and under the same maximums as any other benefit
Second and Third Surgical Opinion Second Surgical Opinion Third Surgical Opinion Drugs and Medicine Inpatient Outpatient - Maximum $150 per month Hair Piece (Wig) - 1 per lifetime Transportation Travel by bus, plane or train
Family Transportation Travel by bus, plane or train Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined Family Lodging - up to a maximum of 100 days per Calendar Year
Ambulance Ground Air Maximum of 2 trips per Hospital Confinement for all modes of transportation combined
$200 per trip
$200 per trip
$2,000 per trip
$2,000 per trip
Inpatient Special Nursing Services - Per day of Hospital Confinement
$150 per day
$150 per day
Outpatient Special Nursing Services Up to same number of Hospital Confinement days
$150 per day
$150 per day
N/A
N/A
$25 per visit $1,000
$25 per visit $1,000
Waive Premium
Waive Premium
Medical Equipment - Maximum of 1 benefit per Calendar Year Physical, Occupational, Speech, Audio Therapy & Psychotherapy Maximum per Calendar Year Waiver of Premium
34
APSB-22338(TX) MGM/FBS Port Neches Groves ISD
GC12 Limited Benefit Group Cancer Indemnity Insurance Benefit Riders Internal Cancer First Occurrence Benefit Rider
Level 1
Level 2
Lump Sum Benefit Maximum 1 per Covered Person per lifetime
$2,500
$2,500
Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime
$3,750
$3,750
Heart Attack/Stroke First Occurrence Benefit Rider
Level 1
Level 1
Lump Sum Benefit Maximum 1 per Covered Person per lifetime
$2,500
$2,500
Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime
$3,750
$3,750
Intensive Care Unit
$600 per day
$600 per day
Step Down Unit Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit
$300 per day
$300 per day
Hospital Intensive Care Unit Rider
Monthly Premiums* OPTION 1 TOTAL MONTHLY PREMIMS BY PLAN**
Issue Ages
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
18+
$20.64
$43.80
$26.70
$49.80
OPTION 2 TOTAL MONTHLY PREMIUMS BY PLAN**
Issue Ages
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
18+
$26.90
$56.62
$34.14
$63.86
*The premium and amount of benefits vary dependent upon Plan selected at time of application. **Total premium includes the Plan selected and any applicable rider premium.
35
APSB-22338(TX) MGM/FBS Port Neches Groves ISD
GC12 Limited Benefit Group Cancer Indemnity Insurance
Plan Benefit Highlights Cancer Screening Benefits Diagnostic Testing
Pays the indemnity amount for one test per Calendar Year when a Covered Person receives a screening test that is generally medically recognized to detect internal cancer. The test must be performed after the 30-day period following the Covered Person’s effective date for this benefit to be paid. This benefit is payable without a diagnosis of Cancer. This benefit ONLY pays for a screening test and does not include any test payable under the Medical Imaging benefit.
Follow-Up Diagnostic Testing
Pays the indemnity amount for one follow-up invasive screening test per Calendar Year when a Covered Person receives abnormal results from a covered screening test. For tests involving an incision or surgery, this benefit will only be paid for a test that results in a negative diagnosis of Cancer. Diagnostic surgeries that result in a positive diagnosis of Cancer will be paid under the Surgical benefit.
Anesthesia
Pays 25% of the paid Surgical benefit amount for services of an anesthesiologist as a result of a covered surgery. Services of an anesthesiologist for Bone Marrow or Stem Cell Transplants are covered under the Bone Marrow or Stem Cell Transplant benefits. Services of an anesthesiologist for Skin Cancer or surgical prosthesis implantation are not covered under this benefit.
Bone Marrow/Stem Cell Transplant
Pays an indemnity amount once per lifetime when a bone marrow or stem cell transplant is performed on a Covered Person as treatment for a diagnosed Cancer. This benefit is payable in or out of the Hospital and is payable in lieu of the Surgical and Anesthesia benefits. If a bone marrow and a stem cell transplant are performed on the same day, only the Bone Marrow Transplant benefit will be payable.
Prosthesis
Medical Imaging
Pays the indemnity amount, up to the maximum number of tests per Calendar Year, when a Covered Person has been diagnosed with Cancer and receives a MRI, CT scan, CAT scan or PET scan. These tests must be at the request of a Physician.
Pays an indemnity amount once per lifetime for a non-surgical or a surgically implanted prosthetic device prescribed by a Physician as a direct result of surgery for Cancer. The Cancer must have manifested after the 30 days following the Effective Date. This benefit does not cover prosthetic related supplies. Artificial limbs will be paid under the surgical implantation portion of this benefit. Temporary prosthetic devices used as tissue expanders are covered under the Surgical benefit. Benefits for hair prosthesis will only be covered under the Hair Piece benefit.
Cancer Treatment Benefits
Patient Care Benefits
Pays actual charges, up to the maximum benefit per 12-month period, when a Covered Person receives treatment and incurs a charge for covered Radiation Therapy, Chemotherapy or Immunotherapy. The 12-month period begins on the first day the Covered Person receives covered Radiation Therapy, Chemotherapy or Immunotherapy. Chemotherapy or Immunotherapy coverage will be limited to drugs only. This benefit does not cover other procedures related to Radiation Therapy, Chemotherapy, Immunotherapy, anti-nausea drugs or any drugs or medicines covered under the Drugs and Medicine benefit or Hormone Therapy benefit.
Pays an indemnity amount when a Covered Person is confined to a Hospital for the treatment of a covered Cancer or the treatment of a condition or disease directly caused by Cancer or the treatment of Cancer. Outpatient treatment or a stay of less than 18 hours in an observation unit or an Emergency Room is not covered. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; or a facility primarily affording custodial, educational care, or care of treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.
Radiation Therapy, Chemotherapy or Immunotherapy
Hormone Therapy
Pays an indemnity amount, up to 12 treatments per calendar year, when hormone therapy treatment is prescribed by a Physician for a Covered Person. This benefit covers drugs and medicine only. This benefit does not cover associated administrative processes or any drugs or medicines covered under the Drugs and Medicine benefit or Radiation Therapy, Chemotherapy or Immunotherapy benefit.
Surgical Benefits Surgical
Pays an indemnity amount when a surgical operation is performed on a Covered Person for a covered diagnosed Cancer, Skin Cancer or for reconstructive surgery due to Cancer. The indemnity amount is payable up to the maximum per operation amount chosen and will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount. This benefit will be paid for surgery performed in or out of the Hospital. Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone Marrow or Stem Cell Transplant surgeries are paid under the Bone Marrow or Stem Cell Transplant benefits. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis benefit. This benefit is payable for reconstructive breast surgery performed on a non-diseased breast to establish symmetry with a diseased breast when the reconstructive surgery of the diseased breast is performed while covered under this policy. Reconstructive surgery to the non-diseased breast must occur within 24 months of the reconstructive surgery of the diseased breast.
36
APSB-22338(TX) MGM/FBS Port Neches Groves ISD
Hospital Confinement
Outpatient Facility
Pays an indemnity amount when a facility fee is charged for a surgical procedure performed on an outpatient basis in a Hospital or at an Ambulatory Surgical Center on a Covered Person for a diagnosed Cancer. Surgical procedures for Skin Cancer performed on an outpatient basis in a Hospital or Ambulatory Surgical Center are not covered under this benefit.
Attending Physician
Pays an indemnity amount for one Physician’s visit per day of Hospital confinement when a Covered Person requires the services of a Physician, other than a surgeon, while confined in a Hospital for the treatment of Cancer.
Extended Care Facility
Pays the indemnity amount when a Covered Person is confined to an Extended Care Facility due to Cancer. Confinement must be at the direction of a Physician and begin within 14 days after a Hospital Confinement. This benefit is payable for the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement.
Home Health Care
Pays the indemnity amount when a Covered Person requires Home Health Care in lieu of Hospital Confinement due to Cancer. Home Health Care must be prescribed by a Physician and provided by a Nurse or by a home health Nurse’s aide under the supervision of a registered Nurse. Confinement must begin within 14 days after a covered Hospital Confinement and is payable up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. The caregiver may not be a member of the Insured’s Immediate Family. This benefit does not include physical, speech or audio therapy, or psychotherapy as these therapies are covered under the Physical, Occupational, Speech or Audio Therapy or Psychotherapy benefit. If the Covered Person qualifies for coverage under the Hospice Care benefit, the Hospice Care benefit will be paid in lieu of this benefit.
GC12 Limited Benefit Group Cancer Indemnity Insurance Hospice Care Pays the indemnity amount, up to the maximum number of days per lifetime, when a Covered Person is diagnosed by a Physician as terminally ill and requires Hospice Care due to Cancer. Care must be directed by a licensed hospice organization in the patient’s home or on an outpatient or short-term Inpatient basis in a hospice facility. The Covered Person is considered terminally ill if expected to live six months or less.
US Government, Charity Hospital or H.M.O. Pays an indemnity amount if an itemized list of services is not available because a Covered Person is confined in a charity Hospital or U.S. Government owned Hospital or covered under a Health Maintenance Organization (H.M.O.) or a Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person. If this option is elected and the Covered Person is confined as an Inpatient in a Hospital as a result of Cancer or Dread Disease, benefits for each full day of confinement will be paid. If outpatient services are provided, we will pay the benefit for each day that outpatient surgery is performed or outpatient therapy is received for Cancer covered by the Policy. This benefit will be paid in lieu of most benefits under the Policy/Certificate.
Miscellaneous Benefits
Cancer Treatment Cancer Evaluation or Consultation Pays the indemnity amount once per lifetime when a Covered Person obtains a treatment opinion at a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the center is located more than 50 miles from the Covered Person’s place of residence, we will also pay a transportation and lodging indemnity amount in lieu of the Transportation and Lodging benefit and Family Member Transportation and Lodging benefit.
Second & Third Surgical Opinion Pays the indemnity amount for a second surgical opinion when the attending Physician recommends surgery for a Covered Person as treatment of a diagnosed Cancer. The second surgical opinion must be obtained from the consulting Physician prior to surgery. If the second surgical opinion does not agree with the first surgical opinion and a third surgical opinion is required, we will pay an indemnity amount for a third surgical opinion. Each surgical opinion is payable once per diagnosis of Cancer. Surgical opinions for reconstructive, Skin Cancer or prosthesis surgeries are not covered under this benefit.
Drugs & Medicine Pays the indemnity amount when anti-nausea and pain medication are prescribed by a Physician and administered to a Covered Person who is also receiving Radiation Therapy, Chemotherapy, Immunotherapy, a covered surgery, Bone Marrow Transplant or Stem Cell Transplant. This benefit does not cover associated administrative processes. This benefit does not include drugs or medicines covered under the Radiation Therapy, Chemotherapy or Immunotherapy benefit or the Hormone Therapy benefit.
Transportation & Lodging Pays the actual coach fare for transportation for a Covered Person by bus, plane or train or the per mile amount for transportation by car, to receive covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. The Hospital must be prescribed by a Physician and be the nearest Hospital which offers the specialized treatment. If the Covered Person travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for transportation will be paid once per Hospital Confinement. Pays the indemnity amount for lodging, up to the maximum number of days, when treatment is received on an outpatient basis. The Covered Person’s lodging must be in a single room in a motel, hotel or other accommodation acceptable to us and will be paid only while the Covered Person is receiving the specialized treatment as an outpatient.
APSB-22338(TX) MGM/FBS Port Neches Groves ISD
Family Transportation & Lodging
Pays the actual coach fare for transportation by bus, plane or train, or the per mile amount for transportation by car for one adult family member to be near a Covered Person who is receiving covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery due to Cancer in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. If the family member travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for travel and/or lodging will be paid once per Hospital Confinement. If treatment for the Covered Person is received on an outpatient basis, we will pay the indemnity amount for lodging, subject to the maximum number of days, for the family member’s lodging in a single room in a motel, hotel or other accommodation acceptable to us. If treatment is received on an outpatient basis, benefits for travel and/or lodging will be paid only on those days the Covered Person received outpatient treatment. If the family member and the Covered Person who is receiving treatment travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging benefit.
Blood, Plasma & Platelets
Pays the indemnity amount for blood, plasma and platelets. This benefit does not include coverage for any laboratory processes or colony stimulating factors. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit.
Ambulance
Pays the indemnity amount, up to two trips per confinement, for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and Hospital confined for at least 18 consecutive hours for the treatment of Cancer. If both air and ground ambulance is required on the same day, we will only pay the highest benefit amount.
Physical, Occupational, Speech, Audio Therapy or Psychotherapy
Pays the indemnity amount, up to the maximum per Calendar Year, when a Covered Person is advised by a Physician to seek physical, occupational, speech, audio therapy or psychotherapy as a result of Cancer or the treatment of Cancer. These therapies must be performed by a caregiver licensed in physical, occupational, speech, audio therapy or psychotherapy. If two or more therapies occur on the same day, only one benefit will be paid.
Waiver of Premium
When the Certificate is in force and the Insured becomes Disabled, we will waive all premiums due including premiums for any riders attached to the Certificate. Disability must be due to Cancer and occur while receiving treatment for such Cancer for which benefits are payable under the Policy. The Insured must remain Disabled for 60 continuous days before this benefit will begin. The Waiver of Premium will begin on the next premium due date following the 60 consecutive days of Disability. This benefit will continue for as long as the Insured remains Disabled until the earliest of either the date the Insured is no longer Disabled or the date coverage ends according to the Termination provisions in the Certificate. Proof of Disability must be provided for each new period of Disability before a new Waiver of Premium benefit is payable. Other Benefits include: s Donor s Dread Disease s Experimental Treatment s Hair Piece s Inpatient Special Nursing Services s Medical Equipment s Outpatient Special Nursing Services 37
See your Policy/Certificate for more information regarding the benefits listed above.
GC12 Limited Benefit Group Cancer Indemnity Insurance Important Policy Provisions Eligibility
You and your Eligible Dependents are eligible to be insured under the Certificate if you and your Eligible Dependents meet APL’s underwriting rules and you are Actively at Work and qualify for coverage as defined in the Master Application.
Limitations & Exclusions
No benefits will be paid for any of the following: s care or treatment received outside the territorial limits of the United States s treatment by any program engaged in research that does not meet the definition of Experimental Treatment s losses or medical expenses incurred prior to the Covered Person’s Effective Date regardless of when Cancer was diagnosed
Only Loss for Cancer or Dread Disease
The Policy/Certificate 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/Certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy/Certificate 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 except for conditions specifically provided in the Dread Disease benefit.
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 PreExisting Condition. Pre-Existing Conditions specifically named or described as excluded in any part of the Policy/Certificate 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 Pre-Existing Condition Limitation for such increase will be based on the effective date of such increase.
Waiting Period
The Policy/Certificate contains 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, the Insured may elect to void the Certificate from the beginning and receive a full refund of premium.
Termination of Coverage
Insurance coverage for a Covered Person under the Certificate and any attached riders for a Covered Person will end as follows: s the date the Policy terminates s the date the Certificate terminates s the end of the grace period if the premium remains unpaid s the end of the Certificate Month in which the Policyholder requests to terminate the coverage for an Eligible Dependent s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent s the date of the Covered Person’s death
Optionally Renewable
The policy is optionally renewable. The Policyholder has the right to terminate the policy on any premium due date after the first Anniversary following the Policy Effective Date. APL must give at least 60 days written notice prior to cancellation.
Portability (Voluntary Plans Only)
When the Insured no longer meets the definition of Insured, he or she 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: s the Certificate has been continuously in force for the last 12 months s APL receives a request and payment of the first premium for the portability coverage no later than 30 days after the date the Insured no longer qualifies as an eligible Insured. All future premiums due will be billed directly to the Insured. The Insured is responsible for payment of all premiums for the portability coverage s the Policy, under which this Certificate was issued, continues to be in force on the date the Insured ceases to qualify for coverage The benefits, terms and conditions of the portability coverage will be the same as those elected under the Certificate immediately prior to the date the Insured exercised portability. Portability coverage may include any Eligible Dependents who were covered under the Certificate at the time the Insured ceased to qualify as an eligible Insured. No new Eligible Dependents may be added to the portability coverage except as provided in the Newborn and Adopted Children provision. No increases in coverage will be allowed while the Insured is exercising his or her rights under this rider.If the Policy is no longer in force, then portability coverage is not available.
If the Policy/Certificate replaced Specified Disease Cancer coverage from another 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 Limitation will still apply.
Termination of Certificate
Insurance coverage under the Certificate and any attached riders will end on the earliest of any of the following dates: s the date the Policy terminates s the end of the grace period if the premium remains unpaid s the date insurance has ceased on all persons covered under this Certificate s the end of the Certificate Month in which the Policyholder requests to terminate this coverage s the date you no longer qualify as an Insured s the date of your death
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 complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | This product contains Limitations & Exclusions | Policy Form GC12APL Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (04/13) | Port Neches Groves ISD 38
APSB-22338(TX) MGM/FBS Port Neches Groves ISD
GC12 Limited Benefit Group Cancer Indemnity Insurance Port Neches Grove ISD
39
UNUM YOUR BENEFITS PACKAGE
Long Term 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 40 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Long Term Disability Policy # 124864
Benefit Dura on
Please read carefully the following descrip on of your Unum Educator Select Income Protec on Plan insurance.
Your dura on of benefits is based on your age when the disability occurs. Plan: ADEA II: Your dura on of benefits is based on the following table:
Eligibility You are eligible for disability coverage if you are an ac ve employee in the United States working a minimum of 17.5 hours per week. The date you are eligible for coverage is the later of: the plan effec ve date; or the day a er you complete the wai ng period.
Guarantee Issue Current Employees: Coverage is available to you without answering any medical ques ons or providing evidence of insurability. You may enroll on or before the enrollment deadline. New Hires: Coverage is available to you without answering any medical ques ons or providing evidence of insurability. You may apply for coverage within 60 days a er your eligibility date. If you do not apply within 60 days a er your eligibility date, you can apply only during an annual enrollment period. Benefits are subject to the pre‐exis ng condi on exclusion referenced later in this document.
Age at Disability Less than age 60 Age 60 through 64 Age 65 through 69 Age 70 and over
Maximum Dura on of Benefits To age 65, but not less than 5 years 5 years To age 70, but not less than 1 year 1 year
Pre‐Exis ng Condi on Exclusion Benefits will not be paid for disabili es caused by, contributed to by, or resul ng from a pre‐exis ng condi on. You have a pre‐exis ng condi on if: you received medical treatment, consulta on, care or services including diagnos c measures, or took prescribed drugs or medicines in the 3 months just prior to your effec ve date of coverage; and the disability begins in the first 12 months a er your effec ve date of coverage.
Please see your Plan Administrator for your eligibility date.
Next Steps How to Apply/Effec ve Date of Coverage
Benefit Amount
Current Employees: To apply for coverage, complete your enrollment form by the enrollment deadline. Please see your Plan Administrator for your effec ve date.
You may purchase a monthly benefit in $100 units, star ng at a minimum of $200, up to 60% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $7,500. Please see your Plan Administrator for the defini on of monthly earnings. The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are par cipa ng in Unum’s Rehabilita on and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).
Elimina on Period The Elimina on Period is the length of me of con nuous disability, due to sickness or injury, which must be sa sfied before you are eligible to receive benefits. You may choose an Elimina on Period (injury/sickness) of 0/7, 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpa ent, benefits begin on the first day of inpa ent confinement. Inpa ent means that you are confined to a hospital room due to your sickness or injury for 23 or more consecu ve hours. (Applies to Elimina on Periods of 30 days or less.)
New Hires: To apply for coverage, complete your enrollment form within 60 days of your eligibility date. Please see your Plan Administrator for your effec ve date. If you do not enroll during the ini al enrollment period, you may apply only during an annual enrollment.
Delayed Effec ve Date of Coverage If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect un l you return to ac ve employment. Please contact your Plan Administrator a er you return to ac ve employment for when your coverage will begin.
Ques ons If you should have any ques ons about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your cer ficate booklet for your complete plan descrip on. If the terms of this plan highlight summary or your cer ficate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP‐1, et al. Underwri en by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ©2007 Unum Group. All rights reserved. Unum is a registered trademark and marke ng brand of Unum Group and its insuring subsidiaries.
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Long Term Disability PORT NECHES-GROVES INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A
Product: Educator Select Income Protection Plan
Injury (Days) Sickness (Days) Maximum Annual Monthly Monthly Earnings Earnings Benefit 3600 300 200 5400 450 300 7200 600 400 9000 750 500 10800 900 600 12600 1050 700 14400 1200 800 16200 1350 900 18000 1500 1000 19800 1650 1100 21600 1800 1200 23400 1950 1300 25200 2100 1400 27000 2250 1500 28800 2400 1600 30600 2550 1700 32400 2700 1800 34200 2850 1900 36000 3000 2000 37800 3150 2100 39600 3300 2200 41400 3450 2300 43200 3600 2400 45000 3750 2500 46800 3900 2600 48600 4050 2700 50400 4200 2800 52200 4350 2900 54000 4500 3000 55800 4650 3100 57600 4800 3200 59400 4950 3300 61200 5100 3400 63000 5250 3500 64800 5400 3600 66600 5550 3700 68400 5700 3800 70200 5850 3900 72000 6000 4000 73800 6150 4100 75600 6300 4200 7740042 6450 4300
ADEA II Duration of Benefits Elimination Period (Days) 0* 7*
14* 14*
30* 30*
60 60
90 90
180 180
9.02 13.53 18.04 22.55 27.06 31.57 36.08 40.59 45.10 49.61 54.12 58.63 63.14 67.65 72.16 76.67 81.18 85.69 90.20 94.71 99.22 103.73 108.24 112.75 117.26 121.77 126.28 130.79 135.30 139.81 144.32 148.83 153.34 157.85 162.36 166.87 171.38 175.89 180.40 184.91 189.42 193.93
7.20 10.80 14.40 18.00 21.60 25.20 28.80 32.40 36.00 39.60 43.20 46.80 50.40 54.00 57.60 61.20 64.80 68.40 72.00 75.60 79.20 82.80 86.40 90.00 93.60 97.20 100.80 104.40 108.00 111.60 115.20 118.80 122.40 126.00 129.60 133.20 136.80 140.40 144.00 147.60 151.20 154.80
5.40 8.10 10.80 13.50 16.20 18.90 21.60 24.30 27.00 29.70 32.40 35.10 37.80 40.50 43.20 45.90 48.60 51.30 54.00 56.70 59.40 62.10 64.80 67.50 70.20 72.90 75.60 78.30 81.00 83.70 86.40 89.10 91.80 94.50 97.20 99.90 102.60 105.30 108.00 110.70 113.40 116.10
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
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
2.72 4.08 5.44 6.80 8.16 9.52 10.88 12.24 13.60 14.96 16.32 17.68 19.04 20.40 21.76 23.12 24.48 25.84 27.20 28.56 29.92 31.28 32.64 34.00 35.36 36.72 38.08 39.44 40.80 42.16 43.52 44.88 46.24 47.60 48.96 50.32 51.68 53.04 54.40 55.76 57.12 58.48
Long Term Disability PORT NECHES-GROVES INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A Product: Educator Select Income Protection Plan Injury (Days) Sickness (Days) Maximum Annual Monthly Monthly Earnings Earnings Benefit 79200 6600 4400 81000 6750 4500 82800 6900 4600 84600 7050 4700 86400 7200 4800 88200 7350 4900 90000 7500 5000 91800 7650 5100 93600 7800 5200 95400 7950 5300 97200 8100 5400 99000 8250 5500 100800 8400 5600 102600 8550 5700 104400 8700 5800 106200 8850 5900 108000 9000 6000 109800 9150 6100 111600 9300 6200 113400 9450 6300 115200 9600 6400 117000 9750 6500 118800 9900 6600 120600 10050 6700 122400 10200 6800 124200 10350 6900 126000 10500 7000 127800 10650 7100 129600 10800 7200 131400 10950 7300 133200 11100 7400 135000 11250 7500
ADEA II Duration of Benefits Elimination Period (Days) 0* 7*
14* 14*
30* 30*
60 60
90 90
180 180
198.44 202.95 207.46 211.97 216.48 220.99 225.50 230.01 234.52 239.03 243.54 248.05 252.56 257.07 261.58 266.09 270.60 275.11 279.62 284.13 288.64 293.15 297.66 302.17 306.68 311.19 315.70 320.21 324.72 329.23 333.74 338.25
158.40 162.00 165.60 169.20 172.80 176.40 180.00 183.60 187.20 190.80 194.40 198.00 201.60 205.20 208.80 212.40 216.00 219.60 223.20 226.80 230.40 234.00 237.60 241.20 244.80 248.40 252.00 255.60 259.20 262.80 266.40 270.00
118.80 121.50 124.20 126.90 129.60 132.30 135.00 137.70 140.40 143.10 145.80 148.50 151.20 153.90 156.60 159.30 162.00 164.70 167.40 170.10 172.80 175.50 178.20 180.90 183.60 186.30 189.00 191.70 194.40 197.10 199.80 202.50
89.32 91.35 93.38 95.41 97.44 99.47 101.50 103.53 105.56 107.59 109.62 111.65 113.68 115.71 117.74 119.77 121.80 123.83 125.86 127.89 129.92 131.95 133.98 136.01 138.04 140.07 142.10 144.13 146.16 148.19 150.22 152.25
77.44 79.20 80.96 82.72 84.48 86.24 88.00 89.76 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
59.84 61.20 62.56 63.92 65.28 66.64 68.00 69.36 70.72 72.08 73.44 74.80 76.16 77.52 78.88 80.24 81.60 82.96 84.32 85.68 87.04 88.40 89.76 91.12 92.48 93.84 95.20 96.56 97.92 99.28 100.64 102.00
43
CIGNA
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 44 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Life and AD&D Basic Term Life Insurance Coverage
Other Coverage Features
(paid by your employer) Employee • Benefit Amount and Maximum – $15,000 • Coverage begins when eligible • Benefit Reduction Schedule – Benefits will reduce to 65% at age 65 and 50% ages 70+
Accelerated Death Benefit — Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 50% of the Voluntary Term Life Insurance coverage amount inforce or $100,000, whichever is less, to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit.
Voluntary Term Life Insurance Coverage (paid by you) Employee – If you are an active, full-time employee and work at least 17.5 hours per week for your employer. • Benefit Amount – Units of $10,000 • Maximum – The lesser of 7 times annual compensation to a maximum of $500,000 rounded to the nearest $1,000 • Guaranteed Issue Amount: The lesser of 7 times annual compensation to a maximum of $200,000 • Coverage begins when eligible Your Spouse — Eligible provided that you apply for and are approved for coverage for yourself. • Benefit Amount – Units of $5,000 • Maximum – $100,000 • Guaranteed Issue Amount: $50,000 • Coverage begins when eligible Your Unmarried, Dependent Children — Up to age 26 , as long as you apply for and are approved for coverage for yourself. • Benefit Amount – $10,000 • Maximum – $10,000 • All Guaranteed Issue • Covers all dependent children No one may be covered more than once under this plan.
Guaranteed Coverage for Voluntary Term Life Insurance Coverage Guaranteed Coverage Amount is the amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed Coverage is only available during Initial Enrollment and other times as approved. If you apply for coverage that is above the Guaranteed Coverage Amount, or if you are applying for coverage after 31 days after you become eligible, you must fill out a Medical Evidence of Insurability form. All dependent child benefits are guaranteed issue.
Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. Conversion If group life insurance coverage is reduced or ends for any reason except nonpayment of premiums, you can convert to an individual policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Family members may convert their coverage as well. Converted policies are subject to certain benefits and limits as outlined in the conversion brochure which may be requested as needed. Premiums may change at this time. Portability This plan allows you to continue all of your voluntary coverage if you leave your employer. Premiums may change at this time. Just pay your premiums directly to the insurance company. Coverage may be continued for you and your spouse until age 70. Coverage may also be continued for your children. Exclusions This plan will not pay benefits if loss of life is the result of suicide that occurs within the first two years of coverage.
45
Life and AD&D How Much Your Voluntary Term Life Insurance Coverage Will Cost Per Month Age
20-24 25-29 30-34 35-39 40-44 45-49
Employee Cost Per $1,000
Spouse Cost Per $1,000
Age
$0.066
$0.066
50-54
$0.066 $0.066 $0.077 $0.099 $0.143 $0.240
$0.066 $0.066 $0.077 $0.099 $0.143 $0.240
55-59 60-64 65-69 70-74 75-79 80+
(costs are subject to change) Employee Spouse Cost Per Cost Per Benefit $1,000 $1,000 Voluntary Child per $10,000 $0.415 $0.415 of Coverage Elected $0.645 $0.645 $1.004 $1.004 $1.802 $1.802 $3.243 $3.243 $5.340 $5.340 $7.469 $7.469
Premium Cost $1.20
*Costs are subject to change
Cost Calculation Example Age 33
Monthly Cost per $1,000 .077
Yours
Benefit 200,000
/ /
1,000 1,000
Monthly Cost $15.40
Basic Personal Accident Insurance Coverage
Additional Benefits
(paid by your employer)
For Wearing a Seatbelt & Protection by an Airbag Additional 10% benefit but not more than $25,000 if a covered person dies directly and independently of all other causes from a covered automobile accident while wearing a seatbelt and riding in a private passenger automobile. We will increase the benefit by an additional 5% but not more than $10,000 if the insured person was also positioned in a seat protected by a properly functioning and properly deployed Supplemental Restraint System (Airbag).
Employee • Benefit Amount and Maximum – $15,000 • Coverage begins September 1st • Benefit Reduction Schedule – Benefits will reduce to 65% at age 65, 50% at ages 70+
Voluntary Personal Accident Insurance Coverage (paid by you) Employee - If you are an active, full-time employee and work at least 17.5 hours per week for your employer. • Benefit Amount – Units of $10,000 • Coverage begins September 1st • Benefit Reduction Schedule – Providing you are still employed, your benefits will reduce to 65% at age 65, 50% at ages 70+ Family Plan - Eligible provided that you apply for and are approved for coverage for yourself. •
•
Benefit Amount – 100% of elected amount to the maximum, 50% for spouse if no children, 40% for spouse if eligible children, 10% for children if eligible spouse, 15% for children if no spouse Coverage begins September 1st
No one may be covered more than once under this plan. 46
For Comas 1% of full benefit amount, for up to 11 months, if you are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid. For Exposure & Disappearance Benefits are payable if you suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident. If your or an insured family member’s body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident. For Child Care Expenses If you die as a result of a covered accident, we will pay a benefit for a surviving child under 13 who is enrolled in a licensed child
Life and AD&D care center at the time of the accident or within 90 days afterwards. This benefit is 3% of your benefit amount per year, but not more than $3,000 per year for 4 years or until the child turns 13, whichever occurs first, for each covered child. For Spouse Training Reimburse covered Spouse who receives education/training for employment within three years of the covered employee’s death as a result of a loss. Additional Benefit of $3,000 What is Not Covered Self-inflicted injuries or suicide while sane or insane; commission or attempt to commit a felony or an assault; any act of war, declared or undeclared; any active participation in a riot, insurrection or terrorist act; bungee jumping; parachuting; skydiving; parasailing; hang-gliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew. When Your Coverage Begins and Ends Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid.
A Valuable Combination of Benefits To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below.
If, within 365 days of a covered accident, bodily injuries result in: • Loss of life • Total paralysis of upper and
We will pay this % of the benefit amount: 100%
lower limbs, or • Loss of any combination of two:
hands, feet or eyesight, or
100%
• Loss of speech and hearing in
both ears • Total paralysis of both lower or •
• • • • •
upper limbs Total paralysis of upper and lower limbs on one side of the body, or Loss of hand, foot or sight in one eye, or Loss of speech or loss of hearing in both ears, or Severance and Reattachment of one hand or foot Total paralysis of one upper or lower limb, or Loss of all four fingers of the same hand, or Loss of thumb and index finger of the same hand Loss of all toes of the same foot
• • Coma
75%
50%
25%
20% 1%
47
5STAR LIFE
Individual Life
About this Benefit Group termlife lifeis isa policy the most to Individual thatinexpensive provides a way specified purchase life insurance. You have at thethe freedom death benefit to your beneficiary time ofto select amount of lifeofinsurance death.an The advantage having ancoverage individualyou lifeneed to help protect theopposed well-being your family. insurance plan as to aofgroup 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 48 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Term Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected. If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis—4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance. Benefits are paid for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or • A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision. Example
Weekly Premium
Death Benefit
Accelerated Benefit
Your age at issue: 35
$10.00
$89,655
4% $3,586.20 a month
Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages newborn through 23. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.
For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary.
* Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.
49
Term Life with Terminal Illness and Quality of Life Rider
Age on App. Date 18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 50
$10,000 $7.56 $7.58 $7.65 $7.74 $7.88 $8.07 $8.27 $8.49 $8.73 $9.00 $9.30 $9.64 $10.02 $10.41 $10.84 $11.31 $11.83 $12.41 $13.00 $13.63 $14.28 $14.97 $15.69 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.27 $25.93 $27.66 $29.42 $31.23 $33.12 $35.08 $37.13 $39.31 $41.68 $44.33
MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $12.40 $20.46 $28.52 $36.58 $7.56 $10.78 $14.01 $12.46 $20.58 $28.71 $36.83 $7.58 $10.83 $14.08 $12.63 $20.92 $29.21 $37.50 $7.65 $10.97 $14.28 $12.85 $21.38 $29.90 $38.42 $7.74 $11.15 $14.56 $13.21 $22.08 $30.96 $39.83 $7.88 $11.43 $14.98 $13.67 $23.00 $32.33 $41.67 $8.07 $11.80 $15.53 $14.17 $24.00 $33.83 $43.67 $8.27 $12.20 $16.13 $14.73 $25.13 $35.52 $45.92 $8.49 $12.65 $16.81 $15.31 $26.29 $37.27 $48.25 $8.73 $13.12 $17.51 $16.00 $27.67 $39.33 $51.00 $9.00 $13.67 $18.33 $16.75 $29.17 $41.58 $54.00 $9.30 $14.27 $19.23 $17.60 $30.88 $44.15 $57.42 $9.64 $14.95 $20.26 $18.54 $32.75 $46.96 $61.17 $10.02 $15.70 $21.38 $19.52 $34.71 $49.90 $65.08 $10.41 $16.48 $22.56 $20.60 $36.88 $53.15 $69.42 $10.84 $17.35 $23.86 $21.77 $39.21 $56.65 $74.08 $11.31 $18.28 $25.26 $23.08 $41.83 $60.58 $79.33 $11.83 $19.33 $26.83 $24.52 $44.71 $64.90 $85.08 $12.41 $20.48 $28.56 $26.00 $47.67 $69.33 $91.00 $13.00 $21.67 $30.33 $27.56 $50.79 $74.02 $97.25 $13.63 $22.92 $32.21 $29.19 $54.04 $78.90 $103.75 $14.28 $24.22 $34.16 $30.92 $57.50 $84.08 $110.67 $14.97 $25.60 $36.23 $32.73 $61.13 $89.52 $117.92 $15.69 $27.05 $38.41 $34.56 $64.79 $95.02 $125.25 $16.43 $28.52 $40.61 $36.54 $68.75 $100.96 $133.17 $17.22 $30.10 $42.98 $38.69 $73.04 $107.40 $141.75 $18.08 $31.82 $45.56 $41.10 $77.88 $114.65 $151.42 $19.04 $33.75 $48.46 $43.90 $83.46 $123.02 $162.58 $20.16 $35.98 $51.81 $47.00 $89.67 $132.33 $175.00 $21.40 $38.47 $55.53 $50.48 $96.63 $142.77 $188.92 $22.79 $41.25 $59.71 $54.17 $104.00 $153.83 $203.67 $24.27 $44.20 $64.13 $58.33 $112.33 $166.33 $220.33 $25.93 $47.53 $69.13 $62.65 $120.96 $179.27 $237.58 $27.66 $50.98 $74.31 $67.04 $129.75 $192.46 $255.17 $29.42 $54.50 $79.58 $71.56 $138.79 $206.02 $273.25 $31.23 $58.12 $85.01 $76.29 $148.25 $220.21 $292.17 $33.12 $61.90 $90.68 $81.19 $158.04 $234.90 $311.75 $35.08 $65.82 $96.56 $86.31 $168.29 $250.27 $332.25 $37.13 $69.92 $102.71 $91.77 $179.21 $266.65 $354.08 $39.31 $74.28 $109.26 $97.71 $191.08 $284.46 $377.83 $41.68 $79.03 $116.38 $104.33 $204.33 $304.33 $404.33 $44.33 $84.33 $124.33
Term Life with Terminal Illness and Quality of Life Rider
Age on App. Date 66* 67* 68* 69* 70*
$10,000 $44.93 $48.25 $52.03 $56.33 $61.17
MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $105.81 $207.29 $308.77 $410.25 $44.93 $85.52 $126.11 $114.13 $223.92 $333.71 $443.50 $48.25 $92.17 $136.08 $123.58 $242.83 $362.08 $481.33 $52.03 $99.73 $147.43 $134.31 $264.29 $394.27 $524.25 $56.33 $108.32 $160.31 $146.42 $288.50 $430.58 $572.67 $61.17 $118.00 $174.83
*Quality of Life Rider not available ages 66-70. Quality of Life Rider benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 15 days through age 23). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.
51
ID WATCHDOG
Identity Theft
YOUR BENEFITS PACKAGE
About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.
An identity is stolen every 2 seconds, and takes over
300 hours
to resolve, causing an average loss of $9,650.
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 Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Identity Theft Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.
Identity theft devastates it’s victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.
Repairing the damage caused by identity theft is frustrating and time consuming.
ID Watchdog Monthly Rates 1B
Platinum
Individual Plan
$7.95
$11.95
Family Plan
$14.95
$22.95
ID Watchdog Services Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee
The average victim spends 330 hours repairing the damage from identity theft—the equivalent of working a full-time job for more than 2 months.
The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.
Who’s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies
53
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 54 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
Medical Transport MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network, which means you are covered anywhere.
THE TRUTH... Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or critical care transport. The reality is that a majority of Americans are only partially covered for these high costs. Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill. You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill.
MASA MTS for Employees Ensures... • • • • • •
NO health questions NO age limits NO claim forms NO deductibles NO provider network limitations NO dollar limits on emergency transport costs
What is Covered? • • •
Emergency Helicopter Transport Emergency Ground Ambulance Transport Repatriation
How Much Does It Cost? MASA Emergent rates are $14 a month, per employee/ family coverage.
We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short. “All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015
55
NBS
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 unless your plan contains a $500 rollover or grace period provision.
Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.
FLIP TO‌ 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 56 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd
FSA (Flexible Spending Account) NBS Flexcard
When Will I Receive My Flex Card?
You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. You must file web or paper claims or enroll in continual reimbursement.
Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!
NBS Prepaid MasterCard® Debit Card
For a list of sample expenses, please refer to your district’s benefit website: www.mybenefitshub.com/portnechesgrovesisd
NBS Contact Information: Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you need a replacement card please contact NBS directly at (800) 274-0503.
8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: service@nbsbenefits.com
New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.
DID YOU KNOW?
Medical FSA Annual Contribution Max:
FSAs use tax-free funds to help pay for your Health Care Expenses.
$2,700
Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com • • • •
Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs
57
FSA Frequently Asked Questions What is a Flexible Spending Account?
How Do I File A Claim?
A Flexible Spending Account allows you to save money by paying out-of-pocket health related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.
In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/portnechesgrovesisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.
How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance and health-related expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it -or- lose-it. Remember to retain all your receipts.
Health Care Expense Account Example Expenses: • • • • • • • • • •
Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid
• • • • • • • • •
Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers
What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenefitshub.com/portnechesgrovesisd
What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year. Up to $500 of unused funds will be rolled over to the next year's balance. Contributions are use-it-or- lose-it. Remaining funds in excess of the $500 rollover will be forfeited. Remember to retain all your receipts (including receipts for card swipes).
58
Dependent Care Flex for Day Care no longer offered by your employer.
How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.
Get Your Money 1. 2. 3. 4.
Complete and sign a claim form (available on our website) or an online claim. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.
NBS Flexcard—FSA Pre-paid Benefit Card Your employer sponsors the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.
Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes: • Detailed claim history and processing status • Health Care and Dependent Care account balances • Claim forms, worksheets, etc. • Online Claim Submission
Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer offers a $500 annual rollover provision. This means that a maximum of $500 of unused funds will roll over to the next plan year to use for qualified expenses.
59
WWW.MYBENEFITSHUB.COM/ PORTNECHESGROVESISD 60