FORT WORTH ISD
BENEFIT GUIDE EFFECTIVE: 09/01/2020 - 8/31/2021 WWW.MYBENEFITSHUB.COM/FORTWORTHISD 1
Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS Medical EECU Health Savings Account (HSA) Higginbotham Flexible Spending Account (FSA) United Concordia Dental Indemnity Humana Dental DHMO and Advantage Humana Vision The Hartford Long Term Disability American Public Life Cancer MetLife Optional Life and AD&D Texas Life Permanent Life CHUBB Accident Texas Legal Services January Savings Plan MASA Medical Transportation
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3 4-5 6-13 6 7 8 9 10
11 12-15 16-17 18-27 28-29 30-39 40-43 44-63 64-67 68-73 74-77 78-81 82-87 88-89 90-92
FLIP TO... PG. 4
HOW TO ENROLL
PG. 6
SUMMARY PAGES
PG. 12
YOUR BENEFITS
Benefit Contact Information FINANCIAL BENEFIT SERVICES
FLEXIBLE SPENDING ACCOUNT
HEALTH SAVINGS ACCOUNT
Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/fortworthisd
Higginbotham P: (866) 419-3519 F: (817) 882-9267 www.mywealthcareonline.com/ higginbotham
EECU (817) 882-0800 www.eecu.org
FWISD BENEFITS OFFICE
DENTAL DHMO
DENTAL INDEMNITY
(817) 814-2240 www.fwisd.org Email: benefits@fwisd.org
Group # 573701 Humana (800) 979-4760 www.humanadental.com
Group # 821479-000/001/002/003 United Concordia (800) 332-0366 www.ucci.com
TRS-ACTIVECARE MEDICAL
DENTAL ADVANTAGE
COBRA (DENTAL, VISION)
Blue Cross Blue Shield of Texas (866)355-5999 www.bcbstx.com/trsactivecare
Group # 573701 Humana (800) 979-4760 www.humanadental.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
SCOTT & WHITE HMO MEDICAL
LEGAL SERVICES
COBRA (MEDICAL)
Scott & White (800) 321-7947 www.trs.swhp.org
Texas Legal (800) 252-9346 www.texaslegal.org
BSwift (833) 682-8972
FIRSTCARE MEDICAL
PERMANENT LIFE
HIGGINBOTHAM
FirstCare (800) 884-4901 www.firstcare.com/trs
Texas Life (817) 545-3900 ext. 102 www.texaslife.com
Higginbotham (817) 347-7031 www.higginbotham.net
OPTIONAL LIFE AND AD&D
DISABILITY
403(B) PLAN / 457 PLAN
Group # 122673-1-G MetLife (800) 638-6420 www.metlife.com
Group # 395332 The Hartford (866) 278-2655 www.thehartfordatwork.com
TCG Administrators (800) 943-9179 www.tcgservices.com
VISION
CANCER
JANUARY SAVINGS PLAN
Humana (866) 537-0229 www.humanavisioncare.com
Group # 18296 American Public Life (800) 256-8606 www.ampublic.com
Fort Worth ISD Payroll Department (817) 814-2180 www.fwisd.org
MEDICAL TRANSPORTATION MASA (800) 423-3226
ACCIDENT
www.masamts.com
Group # BKRC671 CHUBB (866) 445-8874 www.combinedinsurance.com/us-en/ Corporate/Abou-Chubb.aspx 3
MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS FWISD” to 313131 and get access to everything you need to complete your benefits enrollment:
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•
Benefit Information
•
Online Support
•
Interactive Tools
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And more.
Text “FBS FWISD” to 313131 OR SCAN
How to Log In
1 BENEFIT INFO
INTERACTIVE TOOLS
2 3
www.mybenefitshub.com/fortworthisd
CLICK LOGIN
ENTER USERNAME & PASSWORD Benefits are available for spouses (including same sex). If you have any questions, please contact benefits@fwisd.org or (817) 8142240.
ONLINE SUPPORT
Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. If you have six (6) or less characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: Last Name (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number 5
Annual Benefit Enrollment
SUMMARY PAGES
Benefit Updates - What’s New: MEDICAL The TRS-ActiveCare provider is changing from Aetna to Blue Cross Blue Shield of Texas on September 1, 2020. All TRSActiveCare participants have three plan options. NEW TRSActiveCare Primary offers: copays for doctor visits before you meet your deductible, Statewide Network, PCP designation required, and No out-of-network coverage. TRS-ActiveCare HD offers: reduced premiums on family and child tiers, HSA compatible, Nationwide network with No out-of-network coverage, and you must meet your deductible before plan pays for non-preventative care. TRS-ActiveCare Primary+ formerly the Select plan offers: copays for many services and drugs, Statewide network, PCP designation required, referrals to see specialists, and No out-of-network coverage. TRS-ActiveCare 2 is closed to new enrollees.
in THEbenefitsHUB, then Open Enrollment will be your opportunity to re-elect their coverage.
OPTIONAL LIFE WITH AD&D Metlife is offering Guarantee Issue (GI) Open Enrollment for all Fort Worth ISD employees. You will have the opportunity to purchase Optional Life with AD&D for yourself up to $250,000 without health questions asked. You can also enroll your spouse up to $50,000 and children to $15,000 in Optional Life with AD&D without health questions, this year only. You MUST add all eligible dependents to THEbenefitsHUB in order to enroll them in Optional Life Insurance with Metlife. If you were previously enrolled in this benefit but did not have your dependents listed
ONLINE ENROLLMENT Online Benefit Portal: www.mybenefitshub.com/fortworthisd. You have access to benefit information 24/7 on the employee benefit portal provided. You can review and print the consolidated enrollment form, benefit guide, download claim forms and plan summaries, links to carrier websites and provider searches.
• • • • •
BASIC LIFE INSURANCE Eligible employees of Fort Worth ISD may receive up to $15,000 Basic Life Insurance coverage provided by FWISD effective 9/1/2020. Be sure to login to THEbenefitsHUB and verify your coverage and designate your beneficiary. DENTAL PPO Dental with United Concordia is now offering a 3rd cleaning per year at no additional cost to enrolled members. Your plan is also offering a Preventative Incentive® program that removes Diagnostic/Preventative Services from being applied toward your annual maximum of $1,500 per person, per year.
Login and complete your benefit enrollment from 07/21/2020 - 08/21/2020 Login assistance is available by calling the FWISD Benefits Department at 817-814-2240 7/21/2020 through 7/30/2020 office hours are Monday through Thursday, 7:30 am to 5:00 pm 8/3/2020 through 8/21/2020 office hours are Monday through Friday, 8:00 am to 5:00 pm Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 Monday-Friday 8am-7pm. REQUIRED: Provide correct dependent social security numbers.
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SUMMARY PAGES
Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.
CHANGES IN STATUS (CIS):
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of the event and meet with your Benefit Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
QUALIFYING EVENTS
Marital Status
A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
Change in Number of Tax Dependents
A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.
Change in Status of Employment Affecting Coverage Eligibility
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage. Eligibility for Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Government Programs
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SUMMARY PAGES
Annual Enrollment During your annual enrollment period, you have the opportunity
Where can I find forms?
to review, change or continue benefit elections each year.
For benefit summaries and claim forms, go to your school
Changes are not permitted during the plan year (outside of
district’s benefit portal:
annual enrollment) unless a Section 125 qualifying event occurs.
www.mybenefitshub.com/fortworthisd. Click on the benefit plan you need information on (i.e., Dental) and you can find
•
Changes, additions or drops may be made only during the
the forms you 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
Please go to: www.mybenefitshub.com/fortworthisd. Click on the benefit plan you need information on (i.e., Dental) and
included in the dependent profile. Additionally, you must
you can find provider search links under the Quick Links
notify your employer of any discrepancy in personal and/or
section.
benefit information. When will I receive ID cards?
•
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.
If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that
New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within 31 calendar days from your date of hire. Failure to complete elections during this time frame will result in forfeiture of coverage.
Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits department or you can call Financial Benefit Services at 866-914-5202 for assistance. 8
time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
SUMMARY PAGES
Employee Eligibility Requirements Medical and Supplemental Benefits: Employees who are active
Dependent Eligibility Requirements
contributing TRS members are eligible for all benefits. Employees
You can cover eligible dependent children under a benefit
who are not active contributing TRS members are eligible to
that offers dependent coverage, provided you participate in
participate in TRS ActiveCare. Eligibility criteria may be found at
the same benefit, through the maximum age listed below.
www.fwisd.org. Click on departments, click on benefits, then
Dependents cannot be double covered by married spouses
select Eligibility. Benefits eligible employees must be actively at
within the Fort Worth ISD or as both employees and
work on the plan effective date for new benefits to be effective,
dependents.
meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan
COBRA Administrator:
effective date. For example, if your 2020 benefits become
National Benefit Services (NBS)
effective on September 1, 2020, you must be actively-at-work on
(800) 274-0503
September 1, 2020 to be eligible for your new benefits. PLAN
CARRIER
MAXIMUM AGE
CONTINUATION
Medical
Aetna
26
COBRA—Aetna
Dental
United Concordia
26
COBRA—NBS
Dental
Humana
26
COBRA—NBS
Vision
Humana
26
COBRA—NBS
Disability
The Hartford
N/A
N/A
Basic Life
MetLife
N/A
Conversion*
Optional Life and AD&D
MetLife
26
Individual Life
Texas Life
26
Conversion* Contact TX Life for direct pay*
Medical Flex (FSA)
Higginbotham
IRS Dependent
COBRA—NBS
Dependent Care
Higginbotham
12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes
N/A
Accident
CHUBB
26
Contact CHUBB for direct pay
Health Savings Account
EECU
IRS Dependent covered on your HDHP
Contact EECU for direct pay
Cancer
APL
26
Conversion*
Medical Transportation
MASA
26
Complete application on benefits website to continue Platinum plan
* Contact Carrier within 30 days of loss.
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your Benefit Administrator to request a continuation of coverage. 9
Helpful Definitions
SUMMARY PAGES
Actively at Work
In-Network
You are performing your regular occupation for the employer
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 9/1/2020 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 Issue (GI) The amount of coverage you can elect without answering any
medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.
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(including diagnostic and/or consultation services).
SUMMARY PAGES
HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care taxfree.
TRS-ActiveCare 1-HD Employee Individual
All employers Employee only Employer
High deductible health plan
None
$3,550 single (2020) $7,100 family (2020)
$2,750
Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).
Not permitted
Year-to-year rollover of account balance?
Yes
No. Remaining balances are available through October 31, 2021.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
Description
Employer Eligibility Contribution Source Account Owner Underlying Insurance Requirement Maximum Contribution
Permissible Use Of Funds
FLIP TO FOR HSA INFORMATION
PG. 16
FLIP TO FOR FSA INFORMATION
PG. 18 11
ACTIVECARE / SCOTT & WHITE / FIRSTCARE
Medical
About this Benefit
YOUR BENEFITS PACKAGE
DID YOU KNOW?
Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis More than 70% of adults across the United States are already being diagnosed with a chronic disease.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 12 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Fort Worth Independent School District ActiveCare Plan Rates (Effective 9-1-2020 through 8-31-2021 ) TRSACTIVECARE CENTRAL AND TRS-ACTIVECARE PRIMARY+ NORTH TEXAS TRS-ACTIVECARE HD (FORMERLY 1- (FORMERLY TRS-ACTIVECARE SCOTT & PRIMARY (NEW) HD) Employee SELECT) 2 WHITE Employee Cost Cost Employee Cost Employee Cost Employee Cost 12 Checks Employee Only
$99.00
$110.00
$227.00
$650.00
$264.10
Employee Spouse
$802.00
$833.00
$977.00
$1,935.00
$1,095.06
Employee Child(ren)
$408.00
$428.00
$547.00
$1,106.00
$596.50
$1,014.00
$1,051.00
$1,301.00
$2,340.00
$1,191.56
$727.00
$764.00
$1,014.00
$2,053.00
$904.56
$363.50
$382.00
$507.00
$1,026.50
$452.28
Employee Family Spousal-Both Employees of FWISD* Spousal-One Employee of FWISD and one Other District**
18 Checks Employee Only
$66.00
$73.33
$151.33
$433.33
$176.07
Employee Spouse
$534.67
$555.33
$651.33
$1,290.00
$730.04
Employee Child(ren)
$272.00
$285.33
$364.67
$737.33
$397.67
Employee Family
$676.00
$700.67
$867.33
$1,560.00
$794.37
Spousal-Both Employees of FWISD* Spousal-One Employee of FWISD and one Other District**
$484.67
$509.33
$676.00
$1,368.67
$603.04
$242.34
$254.67
$338.00
$684.34
$301.52
24 Checks Employee Only
$49.50
$55.00
$113.50
$325.00
$132.05
Employee Spouse
$401.00
$416.50
$488.50
$967.50
$547.53
Employee Child(ren)
$204.00
$214.00
$273.50
$553.00
$298.25
Employee Family
$507.00
$525.50
$650.50
$1,170.00
$595.78
Spousal-Both Employees of FWISD* $363.50 $382.00 $507.00 $1,026.50 Spousal-One Employee of FWISD and $181.75 $191.00 $253.50 $513.25 one Other District** TRS-Active Care Rates for employees who do not contribute to TRS
$452.28 $226.14
12 checks Employee Only Employee & Spouse Employee & Child(ren) Employee Family
$386.00
$397.00
$514.00
$937.00
$551.10
$1,089.00
$1,120.00
$1,264.00
$2,222.00
$1,382.06
$695.00
$715.00
$834.00
$1,393.00
$883.50
$1,588.00
$2,627.00
$1,478.56
$1,301.00
$1,338.00 18 Checks
Employee Only
$257.33
$264.67
$342.67
$624.67
$367.40
Employee & Spouse
$726.00
$746.67
$842.67
$1,481.33
$921.37
Employee & Child(ren)
$463.33
$476.67
$556.00
$928.67
$589.00
Employee Family
$867.33
$892.00 24 checks
$1,058.67
$1,751.33
$985.71
Employee Only
$193.00
$198.50
$257.00
$468.50
$275.55
Employee & Spouse
$544.50
$560.00
$632.00
$1,111.00
$691.03
Employee & Child(ren)
$347.50
$357.50
$417.00
$696.50
$441.75
Employee Family
$650.50
$669.00
$794.00
$1,313.50
$739.28 13
2020-21 TRS-ActiveCare Plan Highlights Sept. 1, 2020 — Aug. 31, 2021 All TRS-ActiveCare participants have three plan options. Each is designed with the unique needs of our members in mind. TRS-ActiveCare 2 NEW: TRS-ActiveCare Primary • Lower premium • Copays for doctor visits
TRS-ActiveCare HD • Similar to current 1-HD • Lower premium • Compatible with health savings
TRS-ActiveCare Primary+
(This plan is closed and not accepting new enrollees. If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan.)
• Simpler version of the current Select
• Closed to new enrollees plan • Current enrollees can choose to before you meet deductible • Lower deductible than HD and primary stay in plan • Statewide network account (HSA) plans • Lower deductible • PCP referrals required to see • Nationwide network with out-of • Copays for many services and drugs • Copays for many drugs and specialists -network coverage • Higher premium services Plan summary • Not compatible with health • No requirement for PCPs or • Statewide network • Nationwide network with out-ofsavings account (HSA) referrals • PCP referrals required to see specialists network coverage • No out-of-network coverage • Must meet deductible before • Not compatible with a health savings • No requirement for PCPs or plan pays for non-preventive account (HSA) referrals care • No out-of-network coverage If you make no changes Only employees that choose If you’re currently in TRSIf you’re currently in TRS-ActiveCare Select If you’re currently in TRS-ActiveCare during Annual this new plan during Annual ActiveCare 1-HD and you make no and you make no changes during Annual 2, and you make no changes during Enrollment, you’ll have Enrollment will be enrolled in change during Annual Enrollment, Enrollment, this will be your plan next Annual Enrollment, you will remain the following plan... it. this will be your plan next year. year. in TRS-ActiveCare 2 next year.
Total Monthly Premiums Employee Only Employee and Spouse Employee and Children Employee and Family
$386 $1,089 $695 $1,301
$397 $1,120 $715 $1,338
$514 $1,264 $834 $1,588
$937 $2,222 $1,393 $2,627
Plan Features Type of Coverage Individual/Family Deductible Coinsurance Individual/Family Maximum Out-ofPocket Network Primary Care Provider (PCP) Required
In-Network Coverage Only
In-Network
Out-of-Network
In-Network Coverage Only
$2,500/$5,000
$2,800/$5,600
$5,500/$11,000
$1,200/$3,600
You pay 20% You pay 40% after You pay 30% after deductible after deductible deductible
You pay 20% after deductible
In-Network
Out-of-Network
$1,000/$3,000
$2,000/$6,000
You pay 20% after You pay 40% after deductible deductible
$8,150/$16,300
$6,900/$13,800 $20,250/$40,500
$6,900/$13,800
$7,900/$15,800
$23,700/$47,400
Statewide Network
Nationwide Network
Statewide Network
Nationwide Network
Yes
No
Yes
No
Doctor Visits Primary Care
$30 copay
Specialist
$70 copay
TRS Virtual Health
$0 per consultation
You pay 20% You pay 40% after after deductible deductible You pay 20% You pay 40% after after deductible deductible $30 per consultation
$30 copay $70 copay $0 per consultation
You pay 40% after deductible You pay 40% after $70 copay deductible $0 per consultation $30 copay
Immediate Care Urgent Care Emergency Care TRS Virtual Health
$50 copay
You pay 20% You pay 40% after after deductible deductible
$50 copay
You pay 30% after deductible
You pay 20% after deductible
You pay 20% after deductible
$0 per consultation
$30 per consultation
$0 per consultation
You pay 40% after deductible You pay a $250 copay plus 20% after deductible $0 per consultation
Integrated with medical
Integrated with medical
$200 brand deductible
$200 brand deductible
$15/$45 copay
You pay 20% after deductible
$15/$45 copay
$50 copay
Prescription Drugs Drug Deductible Generics (30-Day Supply / 90-Day Supply) Preferred Brand
You pay 30% after deductible
You pay 25% after deductible
You pay 25% after deductible
Non-preferred Brand
You pay 50% after deductible
You pay 50% after deductible
You pay 50% after deductible
Specialty
You pay 30% after deductible
You pay 20% after deductible
You pay 20% after deductible
What’s New
Leverage Your $0 Preventive Care*
• • • •
• • • • • • • • •
Primary plan with a lower premium and copays Primary+ (formerly Select) decreased premiums by up to 8% Broader networks of health care providers Lower premiums for families with children
Did You Know • • •
Our provider search tool will be available in June. Choosing a PCP helps you meet your health goals faster. Generic medications save money! Ask your provider if your medicine has a generic. 14
$20/$45 copay You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max) You pay 50% after deductible ($100 min/$200 max)/ You pay 50% after deductible ($215 min/$430 max) You pay 20% after deductible ($200 min/$900 max)/ No 90-Day Supply of Specialty Medications
Annual routine physicals (ages 12+) Annual mammogram (ages 40+) Annual OBGYN exam & pap smear (ages 18+) Annual prostate cancer screening (ages 45+) Well-child care (unlimited up to age 12) Healthy diet/obesity counseling (unlimited to age 22; ages 22+ get twenty-six visits per year) Smoking cessation counseling (8 visits per year) Breastfeeding support (six per year) Colonoscopy (ages 50+ once every ten years)
*Available for all plans. See benefits guides for more details.
2020-21 Health Maintenance Organization Plans and Premiums for Select Regions of the State Remember: Remember that when you choose an HMO, you’re choosing a regional network. TRS also contracts with HMOs in certain regions of the state to bring participants in those areas another regional plan option. Central and North Texas Baylor Scott & White HMO
South Texas Blue Essentials HMO
Brought to you by TRS-ActiveCare
Brought to you by TRS-ActiveCare
You can choose this plan if you live in You can choose this plan if you live in one these counties: Austin, Bastrop, one these counties: Cameron, Bell, Blanco, Bosque, Brazos, Hildalgo, Starr, Willacy Burleson, Burnet, Caldwell, Collin, Coryell, Dallas, Denton, Ellis, Erath, Falls, Freestone, Grimes, Hamilton, Hays, Hill, Hood, Houston, Johnson, Lampasas, Lee, Leon, Limestone, Madison, McLennan, Milam, Mills, Navarro, Robertson, Rockwall, Somervell, Tarrant, Travis, Walker, Waller, Washington, Williamson
West Texas Blue Essentials HMO Brought to you by TRS-ActiveCare You can choose this plan if you live in one these counties: Andrews, Armstrong, Bailey, Borden, Brewster, Briscoe, Callahan, Carson, Castro, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Cottle, Crane, Crockett, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Fisher, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Haskell, Hemphill, Hockley, Howard, Hutchinson, Irion, Jones, Kent, Kimble, King, Knox, Lamb, Lipscomb, Llano, Loving, Lubbock, Lynn, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Runnels, San Saba, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Swisher, Taylor, Terry, Throckmorton, Tom Green, Upton, Ward, Wheeler, Winkler, Yoakum
Total Monthly Premiums Employee Only
$551.10
$491.54
$534.42
Employee and Spouse
$1,382.06
$1,182.52
$1,287.58
Employee and Children
$883.50
$766.96
$835.68
$1,478.56
$1,258.52
$1,370.12
In-Network Coverage Only
In-Network Coverage Only
In-Network Coverage Only
$950/$2,850
$500/$1,000
$950/$2,850
You pay 20% after deductible
You pay 20% after deductible
You pay 25% after deductible
$7,450/$14,900
$4,500/$9,000
$7,450/$14,900
Primary Care
$20 copay
$25 copay
$20 copay
Specialist
$70 copay
$60 copay
$70 copay
$50 copay
$75 copay
$500 copay after deductible
You pay 20% after deductible
$50 copay $500 copay before deductible plus 25% after deductible
Employee and Family
Plan Features Type of Coverage Individual/Family Deductible Coinsurance Individual/Family Maximum Out-of-Pocket
Doctor Visits
Immediate Care Urgent Care Emergency Care
Prescription Drugs Drug Deductible Days Supply Generics Preferred Brand Non-preferred Brand Specialty
$150 (excl. generics)
$100
$150
30-Day Supply / 90-Day Supply
30-Day Supply / 90-Day Supply
30-Day Supply / 90-Day Supply
$5/$12.50 copay
$10/$30 copay
$5/$12.50 copay ACA Preventative: $0
30% after deductible
$40/$120 copay
30% after deductible
50% after deductible
$65/$195 copay
50% after deductible
15%/25% after deductible (preferred/ nonpreferred)
You pay 20% after deductible
15%/25% after deductible (preferred/nonpreferred)
trs.texas.gov 15
EECU
HSA (Health Savings Account)
About this Benefit A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.
YOUR BENEFITS PACKAGE
The interest earned in an HSA is tax free.
Money withdrawn for medical spending never falls under taxable income.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 16 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
HSA (Health Savings Account) What is an HSA?
How to Use Your Funds
Health Savings Account (HSA) enables you to save for and conveniently pay for qualified healthcare expenses, while you earn tax-free interest and pay no monthly service fees. Opening a Health Savings Account provides both immediate and long term benefits. The money in your HSA is always yours, even if you change jobs, switch your health plan, become unemployed or retire. Your unused HSA balance rolls over from year to year. And best of all, HSAs have tax-free deposits, tax-free earnings and tax-free withdrawals. And after age 65, you can withdraw funds from your HSA penalty-free for any purpose*.
•
HSA Debit Card – use your EECU HSA Mastercard® debit card to pay healthcare providers at point-of-sale or by following the instructions provided on a bill from a medical provider.
•
Online Bill Pay – sign up, at eecu.org, and use EECU’s free online banking and bill pay to make payments to medical providers directly from your HSA. Online Transfers – use EECU’s online banking or mobile app; reimburse yourself for out-of-pocket expenses by making a transfer from your HSA to your personal checking or savings account. Check – optional HSA checks can be ordered upon request for a fee. You can use these checks to pay healthcare providers and suppliers.
EECU HSA Benefits •
•
Save money tax-free for healthcare expenses – contributions are not subject to federal income taxes and can be made by • you, your employer or a third party* • No monthly service fee – so you can save more and earn more • Earn competitive dividends on your entire balance – Save your receipts – for all qualified medical expenses. compounded daily and paid monthly from deposit to EECU does not verify eligibility. You are responsible for withdrawal making sure payments are for qualified medical expenses. • Conveniently pay for qualified healthcare expenses – with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available How To Manage Your Account upon request, for a nominal fee**) • Online - check your balance, pay healthcare providers and • Free online, mobile and branch access – allows you to arrange deposits; sign-up for online banking at actively manage your account however you prefer www.eecu.org. • Comprehensive service and support – to assist you in • Mobile - EECU’s mobile app allows you to manage your optimizing your healthcare saving and spending account on the go; download “EECU Mobile Banking” in • Federally insured – to at least $250,000 by NCUA Apple’s App Store and Google Play. • Contact Member Service – call 817-882-0800 for help with 2020 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,550 us online at eecu.org or use our secure email. Member Family: $7,100 Service is available Monday through Friday from 8:00am – Catch-Up Contributions: Accountholders who meet the 7:00pm CT, Saturdays from 9am – 1pm CT and closed on qualifications noted below are eligible to make an HSA Sunday. catch-up contribution of an additional $1,000. • Account Statements – monthly statements show all your • Health Savings accountholder account activity for that period. You can receive free online • Age 55 or older (regardless of when in the year an statements or pay $2 per printed statement. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation. Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.
17
HIGGINBOTHAM
FSA (Flexible Spending Account)
YOUR BENEFITS PACKAGE
About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited. However, your plan contains a grace period provision through October 31, 2021.
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 18 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
FSA (Flexible Spending Account) IMPORTANT INFORMATION
What is a Flexible Spending Account?
If I set aside part of my pay, won't I make less money?
A Flexible Spending Account (FSA) is a benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. Then during the year, you can use the funds in the account to pay for qualified expenses with untaxed dollars.
No. For every dollar you set aside to pay qualified expenses, you save FICA and federal income tax withholding. Your net take‐ home pay will increase by the tax you save. Plus, when you pay for a qualified expense or receive a cash reimbursement, it's tax‐ free.
Why should I par cipate in the plan?
Can I change my contribu on during the year?
Your biggest benefit is savings on payroll withholding taxes. You will save $25 to $40 on every $100 you budget to pay for qualified expenses .
What expenses qualify for payment? Most qualified expenses are for goods or services that you'll buy any way. They include health care costs such as copays, doctors' fees, over‐the‐counter items and prescrip ons, dental and eye care expenses and day care expenses for dependents so you can work.
How do I know how much is available for me to spend, and how do I file a claim? Your balance and claim forms are available 24/7 online at higginbotham.wealthcareportal.com or by calling 866‐419‐3519. Filing claims is easy. Just complete a claim form, a ach a copy of the bill and then send it to us. You'll receive your tax‐free reimbursement within 72 hours.
Must money be deposited in my account before I pay expenses or file a claim? No. The en re annual amount you elect for the Health Care Spending Account (Health FSA) is available on the first day. However, only amounts contributed to date are available for the Dependent Care Spending Account (Dependent Care FSA).
I already have health insurance. Why should I par cipate in the Health FSA?
Yes, but only in certain situa ons. For the Health FSA and Dependent Care FSA, you can change your elec on if you have a change in status or if there's a change in employment for you, your spouse or a dependent.
What if I don't use all the money in my account? Generally, contribu ons that aren't used during the plan year are forfeited back to your employer, but changes to IRS may allow extra me to spend your money or to carry over up to $550. Check with your employer to learn your op ons.
What happens to my accounts if I terminate employment? You may request reimbursement for qualified expenses incurred prior to your termina on date.
You do have the op on to enroll in both a HSA and a FSA, however doing so will make your FSA a “Limited” FSA, which means it will only be available for dental and vision expenses. All medical expenses would be processed through your HSA.
The Health FSA is used to pay for expenses not covered by insurance. These include copays, over‐ the‐counter medica ons, glasses, contacts, orthodon cs, prescrip on drugs and more.
I don't use my employer's health insurance. Can I s ll save? Yes. You can s ll set aside money before taxes to budget and pay for qualified expenses. But remember, a qualified expense paid from this plan is not eligible for reimbursement from another plan. 19
FSA (Flexible Spending Account) How FSAs Work When you pay for these expenses with pre‐tax dollars, you pay no social security or federal income tax on your contribu ons. Your taxable income and your taxes are reduced. Case Study Let's say you earn $25,000 per year. And you are paid semi‐monthly, so each paycheck is for gross compensa on of $1,041.67. You have insurance premiums and other expenses eligible for payment through the Health FSA of $62.50 per pay period. Here is a comparison of what your paycheck looks like with and without the Flexible Spending Account:
When you pay for your expenses with pre‐tax dollars, your net income is increased!
Without Plan
With Plan
$1,041.67
$1,041.67
$0
$62.50
Taxable Income FICA Federal
$1,041.67 ($79.69) ($105.42)
$979.17 ($74.91) ($93.41)
Take Home Pay
$856.56
$810.85
Health Care Expenses
($62.50)
($0)
Remaining Income
$794.06
$810.85
Gross Earnings Plan Contribu ons
$33.58 Monthly $402.96 Annually
Savings
When you incur a medical, dental or vision expense, you'll be reimbursed the full amount of the expense at that me, up to your yearly contribu on elec on. FOR EXAMPLE: You're going to contribute $500 for the plan year ($41.67 per month). On January 15, you visit your eye doctor and receive your exam and contact lenses for a total charge of $200.
Submit that receipt online or by fax, email, mail or the mobile app and receive your full $200 back within 24‐72 hours, even though you don't have the $200 in your account at the me.
You are en tled to the en re $500 from day one of the plan year.
Orthodon a Expenses If you're currently paying on an orthodon a contract for yourself, your spouse or your children, you can put that payment aside in your Health FSA and use the WeathCare debit card to make the payment each month to your orthodon st. All we need is a copy of your current contract and the first payment receipt made with the WeathCare debit card. Your monthly orthodon c payments will be substan ated automa cally for the current plan year.
Your account informa on is available online at higginbotham.wealthcareportal.com or by calling 866‐479‐3579 .
20
FSA (Flexible Spending Account) Health Care Expenses That Qualify for Reimbursement Only qualified health care expenses NOT reimbursed by insurance can be claimed on a Flexible Spending Account plan.
Acupuncture Alcoholism treatment Ambulance Ar ficial limbs/teeth Chiroprac cs Chris an Science Prac oner’s fees Contact lenses and solu ons Copayments (doctor, dental, vision, pharmacy) Costs of physical or mental illness confinement Crutches Deduc bles Dental fees (cosme c procedures not eligible) Dentures Diagnos c fees
Drug and medical supplies (syringes, needles, etc.) Endodon st fees Eye examina on fees Eyeglasses prescribed by your doctor Eye surgery (cataracts, LASIK, etc.) Hearing devices and ba eries Home health care Hospital bills Insulin Laboratory fees Laser eye surgery Obstetrics and fer lity Office visits Oral surgery Orthodon c fees Orthopedic devices
Osteopath fees Oxygen Periodon st fees Physician fees (cosme c procedures not eligible) Podiatrist fees Prescribed medicines Psychiatric care Psychologist and psychiatrist fees Radiology Rou ne physicals and other non‐ diagnos c services or treatments Smoking cessa on programs Surgical fees Wheelchair Vitamins with doctor’s le er X‐rays and MRI
Health Care Expenses That Qualify with Health Care Expenses That Do Not a Doctor’s Prescrip on Qualify for Reimbursement
Bedpans Boost/Pediasure Foot spa Massagers Massages Re‐construc ve surgery in connec on with birth defect, disease or accident Ring cushions Special school for disabled children Therapeu c support gloves Weight loss program fees and over‐the‐counter drugs pertaining to a specific disease Wigs for hair loss caused by disease
Concierge medical subscrip ons Cosme c surgery, procedures and/or medica ons Dental bleaching and electronic toothbrushes Hair restora on (procedures, drugs or medica ons) Health club or gym memberships for general health Mail order prescrip ons from another country Marriage and family counseling Premiums you or your spouse pay for insurance coverage (payroll‐deducted premiums sponsored by your employer are eligible under the Premium Only Plan) Weight loss program food supplements Weight loss programs for general health or appearance
21
FSA (Flexible Spending Account) Qualified Over‐the‐Counter Expenses Lice control An sep cs Medicated bandages An sep c wash or ointment for cuts Mo on sickness tablets or scrapes Respiratory s mulant ammonia Benzocaine swabs Sleeping aids Boric acid powder First aid wipes Pain Relief Arthri s pain reliever Iodine ncture Bunion and blister treatments Sublimed sulfur powder Itch relief Asthma Medica ons Orajel Bronchodilator/expectorant tablets/ Pain reliever, aspirin and asthma inhalers non‐aspirin Cold, Flu and Allergy Medica ons Throat pain medica ons Allergy medica ons Health Products Cold relief, cough relief or flu relief Bandages, gauze and related items (liquid , tablets or drops) Blood pressure monitors Homeopathic sinus medica ons Cholesterol test kits and supplies Medicated chest rub Colorectal cancer screening tests Nasal decongestant (drops, inhaler, Condoms and other OTC spray or strips) contracep ves Sinus medica ons, sinus and allergy Contact lens cleaning solu ons nasal spray Crutches , canes , walkers and Vapor patch cough suppressant wheelchairs Ear/Eye Care Denture adhesives Airplane ear protec on Diabe c supplies, including Insulin Ear drops for swimmers Feminine hygiene products Ear water‐drying aid Fer lity monitors Ear wax removal drops First aid kits Homeopathic earache tablets Hearing aids and ba eries Health Aids Heat wraps and cold packs An ‐fungal treatments Home drug tests Diure cs and water pills Hydrogen peroxide Hemorrhoid relief
Incon nence supplies (Depends and Serenity pads) Latex gloves Occlusal guards (for teeth grinding) Oral syringes Ovula on predictor kits Pregnancy test kits Reading glasses and other OTC eyeglasses Rubbing alcohol Thermometers Skin Care Acne medica ons An ‐itch lo on Cold sore/fever blister medica ons Corn and callus removal Eczema cream Medicated bath products Wart removal medica ons Stomach Care Acid reducers Antacid gum Antacid liquid Antacid tablets An ‐diarrhea medica ons Gas preven on (liquid, tablets or drops) Ipecac syrup Laxa ves Pinworm treatment Prilosec Upset stomach medica ons
Over‐the‐Counter Expenses That Do Not Qualify for Reimbursement
Aromatherapy Baby bo les and cups Baby oil Baby wipes Blistex/Chaps ck Breast enhancement system Cosme cs Co on swabs
Dental floss Deodorants Facial care products Feminine care fragrances Hair regrowth Insoles Low calorie foods Low "carb" foods
REIMBURSEMENTS ARE AS SIMPLE AS 1, 2, 3! 1. 2. 3.
Complete a claim form. Provide required documenta on. Submit online or by fax, email, mail or the mobile app.
22
Mouthwash/oral care/toothbrushes Petroleum jelly Shampoo and condi oner Skin care Spa salts Sun clips Sun tanning products
FSA (Flexible Spending Account) FSAStore for Eligible Products The thousands of products that are available at FSA Store are all FSA and HSA eligible or eligible with a prescrip on and can be purchased with your FSA/HSA debit card or any major credit card. Free shipping is offered on orders of at least $50, and prices on brand name products are very compe account that you're using pre‐tax dollars, you generally save up to 40 percent.
ve. When you take into
Visit FSA Store by logging into www.fsastore.com.
FSAStore makes spending your FSA funds easy. The services channel allows you to search for nearby eligible services, such as acupuncture and chiroprac c care. You can browse through a database of more than 300,000 health care providers by zip code. A learning center gives you instant access to common FSA ques ons and answers and is focused on keeping you informed about ongoing changes to FSA and HSA benefits.
ONE-STOP SHOPPING FOR ALL YOUR OTC NEEDS
Over‐the‐Counter Prescrip ons Easily shop for FSA eligible prescrip on products using your FSA/HSA debit card.
23
FSA (Flexible Spending Account) Health Care Spending Account Worksheet Accurate budge ng of out‐of‐pocket medical expenses not reimbursed or covered by insurance is necessary to gain maximum benefit from the Health Care Spending Account. Only expenses that you know you or your family will incur during the plan year can be included in the program. You should consider your cost of deduc bles and coinsurance features of any medical and dental insurance policies as well as those costs not covered by insurance.
PLANNED MEDICAL EXPENSES Known annual medical expenses (not covered by insurance that your en re family will incur during the plan year for the following services): Deduc bles — Coinsurance Prescrip ons and Doctor Visits (Copays) Over‐the‐Counter Medica ons Massage Therapy (RX needed) LASIK Eye Surgery Medical Supplies and Equipment Therapist, Psychologist or Chiropractor Fees Hearing Aids and Supplies Laboratory and X‐ray Expenses
PLANNED DENTAL CARE Your por on of these expenses: Deduc bles Fillings and Crowns Extrac ons, Dentures and Bridgework Oral Surgery Orthodon c Expenses
PLANNED VISION CARE Examina on Glasses/RX Sunglasses Contact Lenses, Solu on and Materials
TOTAL
$
Total Expenses /
(# of pay periods) =
$
This is only a worksheet and just for your use. Visit higginbotham.wealthcareportal.com for more informa on.
24
FSA (Flexible Spending Account) Reasons to Take Advantage of the Tax Savings Now You'll save $25 to $40 on every $100 you budget to pay for qualified expenses. Taking advantage of the Health FSA and Dependent Care FSA doesn't change what you do at tax me. You actually get a "tax refund" on every paycheck a er elec ng the benefits because you pay no tax on the money you set aside each pay period. You decide how much money to put into the plan and where and when to spend the money in your account. This is a great way to budget. A regular amount is deducted from your paycheck, but the en re annual elec on is always available for you to spend on eligible expenses from day one of the plan year. Note: Health Care Reform limits the annual elecƟon for Health FSAs. Check with your employer to learn the maximum amount you can contribute.
Don't worry about it making your social security benefits smaller. Social security benefits are based on your life me earnings history. Yours may be slightly reduced by par cipa ng in the plan. However, tax advisors will tell you that the tax savings you earn today will far outweigh any reduc on in social security benefits. Do you take a deduc on for medical expenses on a Form 1040? If so, you can only do so a er you spend in excess of 7.5‐10 percent of your adjusted gross income for them. The first dollar you pay for unreimbursed medical expenses is not deduc ble on your Form 1040. But through the Health FSA, the very first dollar you spend will earn you 25‐40 percent in tax savings.
Dependent Care Spending Account How it Works You and your spouse must be employed in order to par cipate, or one of you can be a full‐ me student, ac vely looking for work or disabled. Your care provider cannot be your dependent. The debit card cannot be used for dependent child care.
Once you have enrolled in the plan, everything you need can be found on the MyWealthCare website. You can even enter your claim online. Then you just print the claim form and submit it along with your detailed receipts. It only takes a few moments to familiarize yourself with the reimbursement plan online.
The maximum flex deduc on per family per year is $5,000 when filing jointly or head of household and $2,500 when married filing separately. However, the maximum limit for the child tax credit on your federal income tax return is $6,000 and $3,000 ‐ whatever amount you don't deduct from your Flexible Spending Account, you may be able to deduct the difference (up to $3,000 or $6,000 total) on your income tax return.
Don't worry that you cannot afford to have any more money taken out of your paycheck. Expenses That Qualify for Reimbursement Did you know you can get money out of the plan before you put Before and a er school care it in? By joining the plan, you can have it pay your health care expenses in full at the me of service, even before you make your Household service if part of the service is for the care of a qualifying person contribu on. Any care for your children whom you claim as tax It's OK if both you and your spouse enroll in a similar plan at work. dependents under the age of 13 (a child may qualify for only There is no IRS limit on the amount of medical expenses that can part of the year if he/she turns 13 mid‐year) be reimbursed per household. Each employer sets the annual Care for spouse or dependents of any age who spend at least limits for the Health FSA plan. eight hours a day in your home and are mentally or physically incapable of self‐care Flexible Spending Accounts aren't just for people who need prescrip on drugs and have children Expenses That Do Not Qualify for Reimbursement —everyone has medical expenses, not just families. And with the Kindergarten, unless it can be determined that the IRS Revenue ruling, anyone who buys over‐the‐counter (OTC) educa onal part is incidental and cannot be separated from drugs may be reimbursed through the plan. The plan isn't just for the cost of care prescrip on drugs. Things like cough syrup, pain relievers, allergy Overnight camps (only day camps can be considered) medicine, etc. are included.
25
FSA (Flexible Spending Account) Dependent Care Spending Account
Mobile Access
I take a dependent care credit on Form 7040. Will the Dependent Care Spending Account save more? The more you earn, the more you'll save. In addi on, you'll also save social security tax (FICA) with a Dependent Care Spending Account. So, don't wait un l April 15 to take the credit. You can save taxes on every paycheck now.
Benefits at Your Finger ps You can access your employee account informa on on your smartphone with the mobile app for iPhone and Android.
Which is best for you? Visit higginbotham.wealthcareportal.com and use the easy calculator to determine your savings. Are there any nega ves? Because you won't pay social security tax on the amount of gross pay you set aside to pay for qualified expenses, your social security benefits at re rement may be slightly reduced. However, most tax advisors recommend taking advantage of current tax‐ savings opportuni es like the Health FSA and Dependent Care FSA. Also, if disability insurance is paid on a pre‐tax basis, any future benefits you receive will be taxable.
Loca ng and Loading the Mobile App Simply search for "Higginbotham" on the App Store™ for Apple products or on the Google Play™ Store for Android products, and then load as you would any other app. What You Can Do with the Mobile App View detailed account and balance informa on View card ac vity File a claim and upload receipt photos directly from your smartphone Set up email no fica ons to keep you up‐to‐date on all account and health debit card ac vity
How to Use the Mobile App
Keys to Submi ng Your Claims to Avoid Denial We need to know the date of service in order to pay the claim when you submit a dental or doctor bill. Please do not submit "balance forward" or "previous balance" statements. On your doctor visit copays, we need the actual statement from the doctor if the charge is anything other than a copay amount. They will print a statement for you. We need date of service, service rendered, pa ent's name, insurance payments, etc. If the statement is pink or yellow, please make a dark copy before faxing. The pink and yellow copies are not legible when faxed. When submi ng a statement for a coinsurance, deduc ble or hospital expense, please make sure the Explana on of Benefits (EOB) states very clearly the date of service, pa ent name and procedure. The best document to submit is the EOB from your health insurance provider, as all these details will be included once insurance has been processed.
Logging In Use the same username and password you use to log in to higginbotham.wealthcareportal.com.
THANK YOU FOR YOUR HELP
Ge ng Help Click the Help bu on at the bo om right of all pages to access contact informa on for your administrator, who will be able to provide assistance.
Submi ng a complete claim request helps us pay all eligible claims in full and will also eliminate le ers to you reques ng more informa on regarding the reimbursement!
A er logging in, you will be on the home page, which will list your op ons.
Going Home Press the Home bu on at the bo om le corner of any page to return to the home page and start over.
26
FSA (Flexible Spending Account) Debit Card Access
Debit Card FAQs
The WealthCare debit card is a quick and easy way to pay for qualified expenses from your Flexible Spending Account. You have no out‐of‐pocket expense ‐ the money is taken directly out of your account. Plus, you don't have to wait on reimbursement. Access plan documents, le ers and no ces, forms, account balances, contribu ons, investments and other plan informa on or cafeteria plans, health reimbursement arrangements and transit plans Change personal informa on/census data Find contact informa on or the administrator Use 125 tax calculators
What items are auto substan ated? Certain transac ons involving dollar amounts that are consistent with predetermined copay under the plan.
Go to higginbotham.wealthcareportal.com and request your Flex debit card.
Debit Card Procedure
Use your debit card at the me of service (doctor's office, hospital, pharmacy, etc.).
The debit card cannot be used for child care.
Make sure you get an Explana on of Benefits (EOB) or itemized statement for the service rendered.
Hospital: EOB/itemized statement from the doctor with the procedure code and diagnosis code, date of service, name of pa ent and name and address of the provider
Dental/Vision: EOB/itemized statement with the procedure code, date of service, name of pa ent and name and address of the provider
Submit the EOB or itemized statement online or by fax, email, mail or the mobile app. You can either submit the documents a er you have received your services, or you can wait un l you receive an email from the plan reques ng that you send an EOB or itemized statement. You won't get an email for all of your swipes ‐the copays for your doctor visits, prescrip on copays and vision expenses will automa cally substan ate. However, any me you swipe the card for a dental service or any amount other than a copay, you will need to submit the itemized statement or an EOB.
Certain recurring, previously approved expenses (i.e. orthodon a). Certain charges that are substan ated at the me of the sale or if the vendors that par cipate are in the inventory informa on system (IIAS). Purchases at pharmacies and medical providers that don't subscribe to the IIAS are treated as condi onally approved and paid at the me of service; statements must be faxed to substan ate that the purchase was for a qualified expense. i.e.: A den st office could charge you $200 for teeth bleaching. The $200 would be approved at the me of sale, but the member must submit the statement with the required informa on. Since teeth bleaching is not a covered expense, the claim would be denied, and the member would pay back $200 to the plan. A physician could charge $150 for a consult for cosme c surgery. The $150 would be approved at the me of purchase, but cosme c surgery is not a covered item, and the claim is not eligible for reimbursement under IRS guidelines. You would owe the plan $150. A member pays $125 for a qualified medical expense. He/she uses the debit card, sends in the form with the required informa on, and it is marked as eligible in the system. How do I renew my debit card? Your debit card will work for three years ini ally. Check the expira on date on front of the card. If your company has the "grace extension" or "rollover provision" on the prior plan year, the balance will be loaded to your debit card ‐ the system will automa cally look back at the old plan year and apply these expenses to that plan year first. If your card is "suspended" on the last day of your "submission" deadline date, you will be taxed on the amount not substan ated. A le er will be sent to your home on the last day of your plan year to let you know that you will need to substan ate these by submission deadline to avoid being taxed on this amount.
Very Important: If you do not submit the documentaƟon within 60 days from the date you receive the email, your debit card will be suspended unƟl proper substanƟaƟon is received.
27
UNITED CONCORDIA
Dental Indemnity
YOUR BENEFITS PACKAGE
About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.
Roughly 78% of Americans have had at least one cavity by age 17. 80% of the U.S. population has some form of periodontal disease.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 28 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Dental Indemnity Monthly Rates
Employee Only
$41.35
Employee & One Adult
$83.22
Employee & Child(ren)
$92.34
Family
$134.02
Dental Benefits Summary for Fort Worth Independent School District Group Numbers: 821479-000/001/002/003 Network: Elite Plus UnitedConcordia.com | 1-800-332-0366
Benefit Category1
CONCORDIA FLEX PLAN In-Network2 Non-Network2
Class I - Diagnostic/Preventive Services Exams Bitewing X-rays All Other X-rays Cleanings (3 in 12 months) Sealants & Fluoride Treatments Palliative Treatment Nonsurgical Periodontics
100%
100%
80%
80%
50%
50%
50%
50%
Class II - Basic Services Basic Restorative (Fillings) Simple Extractions Space Maintainers Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Endodontics Surgical Periodontics Complex Oral Surgery
Class III - Major Services Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures)
Orthodontics for dependent children to age 19 Diagnostic, Active, Retention Treatment
Included Plan Features Preventive Incentive® • •
Pregnancy Benefit • •
Class I services do not count toward your annual maximum Covers 1 additional cleaning during pregnancy Covers 1 additional periodontal maintenance during pregnancy Scaling and root planing 4 periodontal surgery procedures
Maximums & Deductibles (applies to the combination of services received from network and non-network dentists) Annual Program Deductible (per person/per family) Annual Program Maximum (per person) Lifetime Orthodontic Maximum (per person)
Reimbursement
$50/$150 (Excludes Class I & Orthodontics) $1,500 (Excludes Orthodontics) $1,500
Elite Plus
90th
Representative listing of covered services – certificate of coverage provides a detailed description of benefits. 1. Unmarried dependent children covered to age 26. 2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. 3. United Concordia creates out-of-network charges utilizing FAIR Health data supplemented with our charge data as appropriate. We then calculate the out -of-network charge at the maximum allowable charge of such data. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply. EEM-0161-0514
29
HUMANA
Dental
YOUR BENEFITS PACKAGE
About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.
Good dental care may improve your overall health. Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 30 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
DHMO 150 C Plan with Ortho Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental C Series dental plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect with HumanaDental. • No waiting periods • No claims to file • No annual maximums
Know what your plan covers Attached is a summary of HumanaDental C Series plan benefits which are described in detail in your certificate. You can find your certificate at HumanaDental.com or call 1-800-979-4760. Here’s what you can expect: •
• •
•
You have the freedom to select any participating dentist. To select a dental provider from our network, simply visit HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-979-4760. Life without claim forms! With HumanaDental DHMO plan you pay your dentist directly, when applicable. Your primary dentist will provide all of your routine dental care and any copayment or discounted charges will be paid at the time of service. Copayments are applicable at either a participating general dentist or a participating specialist. If you need a specialty dentist, you may receive a 25 percent discount by using certain participating specialty dentists from our network. Visit HumanaDental.com to find a participating specialist who offers the discount on specialty services.
Questions? Check out HumanaDental.com Call 1-800-979-4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist.
Check your dental IQ anytime Log on to MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.
Rates Employee
$12.66
Employee + Spouse
$22.60
Employee + Child(ren)
$23.96
Family
$31.18 Dependent Max Age Limit: to Age 26
Choose HumanaDental benefits Be healthy Good oral health means more than just an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so.
31
DHMO 150 C Plan with Ortho The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. C plans copayments are applicable at either a participating general dentist or a participating specialist. Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your dental professional, your PCD may decide that you need to see an contracted dental specialist. No referral is necessary to see a network specialist. Specialists services: Should you need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), you may be referred by your participating general dentist, or you may refer yourself to any participating specialist. For C plans and benefits for procedures not listed on the schedule, you may receive a 25 percent discount by visiting certain participating specialists. Visit www.HumanaDental.com to find a participating specialist who offers the discount on specialty services.
Summary of services Appointments D9310
Consultation (diagnostic service provided by dentist other than practitioner providing treatment)
Member Pays $ 15.00
Preventive (cont.)
Member Pays
D1351
Sealant-per tooth
$ 10.00
D1510
Space maintainer—fixed, unilateral
$ 45.00+labΔ
Space maintainer—fixed, bilateral
$ 45.00+labΔ
D9430
Office visit (normal hours)
$ 5.00
D1515
D9440
Office visit (after regularly scheduled hours)
$ 35.00
D1520
Space maintainer—removable, unilateral
$ 85.00+labΔ
Member Pays
D1525
Space maintainer—removable, bilateral
$ 85.00+labΔ
D1550
Recementation of space maintainer
Diagnostic D0120
Periodic oral examination
no charge
D0140
Limited/comprehensive/detailed and extensive oral eval
no charge
Restorative
D0150
Limited/comprehensive/detailed and extensive oral eval
no charge
D2140
Amalgam—one surface, primary or permanent
no charge
D0160
Limited/comprehensive/detailed and extensive oral eval
no charge
D2150
Amalgam—two surfaces, primary or permanent
no charge
D0180
Comprehensive periodontal evaluation
D0210
X-ray intraoral—complete series including bitewings
no charge
D2160
Amalgam—three surfaces, primary or permanent
no charge
D0220
X-ray intraoral—periapical, first film
no charge
D2161
Amalgam—four or more surfaces, primary or permanent
no charge
D0230
X-ray intraoral—periapical, each additional film
no charge
D2940
Sedative filling
D0270
X-ray bitewing—single film
no charge
D2999
Sedative base (under fillings), by report
D0272
X-ray bitewings—two films
no charge
$ 10.00
D0274
Bitewings—four films
no charge
D0330
Panoramic film
no charge
D0460
Pulp vitality tests
no charge
D0470
Diagnostic casts
no charge
Preventive
Member Pays
Resin Restorative
$ 10.00
Member Pays
$ 15.00 no charge
Member Pays
D2330
Resin based composite—one surface, anterior
$ 35.00
D2331
Resin based composite—two surfaces, anterior
$ 40.00
D2332
Resin based composite—three surfaces, anterior
$ 50.00
D1110
Prophylaxis—adult, routine (once every 6 months)
no charge
D2391
Resin based composite—one surface, posterior
$ 60.00
D1120
Prophylaxis—child, routine (once every 6 months)
no charge
D2392
Resin based composite—two surfaces, posterior
$ 80.00
D1110
Prophylaxis—adult/child, (additional)
$ 20.00
D2393
Prophylaxis—adult/child, (additional)
$ 20.00
Resin based composite—three surfaces, posterior
$ 100.00
D1120
Topical application of fluoride (not including prophylaxis)—child (up to 16 years of age)
D2394 no charge
Resin based composite—four or more surfaces, posterior
$ 120.00
D1203
D2510
Inlay—metallic, one surface
$ 95.00
D1206
Topical fluoride varnish (for child <16)
no charge
D2520
Inlay—metallic, two surfaces
$ 105.00
Oral hygiene instruction
no charge
D2530
Inlay—metallic, three or more surfaces
$ 130.00
D1330
32
DHMO 150 C Plan with Ortho Crown and Bridge
Member Pays
D2740
$ 280.00+labΔ
Crown—porcelain/ceramic substrate
fused to high noble D2750* Crown—porcelain metal
$ 280.00
Crown—porcelain fused to predominantly base metal
$ 280.00
D2751
D2752* Crown—porcelain fused to noble metal
$ 280.00
D2790* Crown—full cast high noble metal
$ 280.00
D2791
Crown—full cast predominantly base metal
$ 280.00
D2792* Crown—full cast noble metal
$ 280.00
D2910
Recement inlay
$ 15.00
D2920
Recement crown
$ 15.00
D2930
Prefabricated stainless steel crown— primary tooth
$ 75.00
D2950
Core buildup, including any pins
$ 45.00
D2951
Pin retention—per tooth, in addition to restoration
$ 15.00
D2952
Cast post and core in addition to crown
$ 90.00+labΔ
D2953
Each additional cast post—same tooth
$ 90.00+labΔ
D2954
Prefabricated post and core in addition to crown
$ 90.00
D2962
Labial veneer (porcelain laminate)— laboratory
$ 280.00+labΔ
Prosthodontics (Fixed)
Member Pays
D6210* Pontic—cast high noble metal
$ 280.00
D6211
$ 280.00
Pontic—cast predominantly base metal
Endodontics
Member Pays
D3330
Root canal therapy—molar (excluding final restoration)
$ 250.00
D3410
Apicoectomy/periradicular surgery— anterior
$ 125.00
Periodontics (Gum Treatment)
Member Pays
D4210
Gingivectomy/gingivoplasty per quadrant
$ 125.00
D4211
Gingivectomy/gingivoplasty per tooth
$ 40.00
D4341
Periodontal scaling and root planing, per quadrant
$ 50.00
D4342
Periodontal scaling and root planing 1 to 3 teeth per quadrant
$ 50.00
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis
$ 45.00
D4381
Localized delivery of chemotherapeutic agents (per tooth)
$ 45.00
D4910
Periodontal maintenance
$ 50.00
Prosthodontics
Member Pays
D5110
Complete denture—maxillary
$ 300.00+labΔ
D5120
Complete denture—mandibular
$ 300.00+labΔ
D5130
Immediate denture—maxillary
$ 300.00+labΔ
D5140
Immediate denture—mandibular
$ 300.00+labΔ
D5211^ Maxillary partial denture—resin base
$ 300.00+labΔ
D5212^ Mandibular partial denture—resin base
$ 300.00+labΔ
D5213^ Maxillary partial denture—cast metal framework, resin denture bases
$ 300.00+labΔ $ 300.00+labΔ
D6212* Pontic—cast noble metal
$ 280.00
fused to high noble D6240* Pontic—porcelain metal
$ 280.00
D5214^ Mandibular partial denture—cast metal framework, resin denture bases
Pontic—porcelain fused to predominantly base metal
$ 280.00
D5410
Adjust complete denture—maxillary
$ 15.00
$ 280.00
D5411
Adjust complete denture—mandibular
$ 15.00
D5421
Adjust partial denture—maxillary
$ 15.00
D5422
Adjust partial denture—mandibular
$ 15.00
D6241
D6242* Pontic—porcelain fused to noble metal fused to high noble D6750* Crown—porcelain metal
$ 280.00
Crown—porcelain fused to predominantly base metal
$ 280.00
D6751
Repairs to Prosthetics
Member Pays
D5510
Repair broken complete denture base
$ 15.00+labΔ
D6752* Crown—porcelain fused to noble metal
$ 280.00
D6790* Crown—full cast high noble metal
$ 280.00
D5520
Replace missing or broken teeth— complete denture (each tooth)
$ 15.00+labΔ
$ 280.00
D5610
Repair resin denture base
$ 15.00+labΔ
$ 280.00
D5630
Repair or replace broken clasp
$ 15.00+labΔ
D5640
Replace broken teeth—per tooth
$ 15.00+labΔ
D5650
Add tooth to existing partial denture
$ 30.00+labΔ
D5730
Reline complete maxillary denture (chairside)
$ 50.00
D6791
Crown—full cast predominantly base metal
D6792* Crown—full cast noble metal D6930
Recement fixed partial denture (per unit)
Endodontics
$ 10.00
Member Pays
D3220
Therapeutic pulpotomy
$ 35.00
D3221
Pulpal debridement, primary and permanent teeth
$ 100.00
D5731
Reline complete mandibular denture (chairside)
$ 50.00
D3310
Root canal therapy—anterior (excluding final restoration)
$ 100.00
D5740
Reline maxillary partial denture (chairside)
$ 50.00
D3320
Root canal therapy—bicuspid (excluding final restoration)
$ 200.00
D5741
Reline mandibular partial denture (chairside)
$ 50.00 33
DHMO 150 C Plan with Ortho Repairs to Prosthetics
Member Pays
D5750
Reline complete maxillary denture (laboratory)
$ 35.00+labΔ
D5751
Reline complete mandibular denture (laboratory)
$ 35.00+labΔ
D5760
Reline maxillary partial denture (laboratory)
$ 35.00+labΔ
D5761
Reline mandibular partial denture (laboratory)
D5850
Tissue conditioning—maxillary
D5851
Tissue conditioning—mandibular
Extractions/Oral & Maxillofacial Surgery
$ 35.00+labΔ
D7140
Extraction, erupted tooth or exposed tooth
no charge
D7210
Surgical removal of erupted tooth
$ 40.00
D7220
Removal of impacted tooth—soft tissue
$ 50.00
D7230
Removal of impacted tooth—partially bony
$ 70.00
D7240
Removal of impacted tooth— completely bony
$ 85.00
D7250
Surgical removal of residual tooth roots
$ 35.00
D7310
Alveoloplasty in conjunction with extractions—per quadrant
$ 35.00
D7311
Alveoplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant
$ 35.00
D7320
Alveoloplasty not in conjunction with extractions—per quadrant
$ 70.00
D7321
Alveoplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant
$ 70.00
D7510
Incision and drainage of abscess— intraoral
$ 25.00
Local anesthesia
D9230
Analgesia (nitrous oxide), per 15 minutes
$ 25.00
D9450
Case presentation, detailed and extensive treatment planning
no charge
D9951
Occlusal adjustment—limited
D9952
Occlusal adjustment—complete
Orthodontics
$ 30.00 no charge
D9215
Palliative (emergency) treatment
Member Pays
Coronal remnants, deciduous tooth
D8070
Consultation
$ 150.00
Member Pays
no charge
Evaluation
$ 35.00
Records/treatment planning
$ 250.00
Orthodontic treatment
D8080
$ 25.00
Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
$ 2,300.00
Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases Consultation
no charge
Evaluation
$ 35.00
Records/treatment planning
$ 250.00
Orthodontic treatment
$ 2,300.00
Comprehensive orthodontic treatment of the adult dentition; Adult 19 years of age and over; Up to 24 months of routine orthodontic treatment for Class I and Class II cases D8090
Consultation Evaluation
Member Pays
Records/treatment planning
no charge $ 15.00
Member Pays
D9110
$ 30.00
D7111
Anesthesia
Adjunctive General Services
Orthodontic treatment D8680
Retention
no charge $ 35.00 $ 250.00 $ 2,500.00 $ 450.00
*The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal. The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal. Δ Patient responsible for lab fees. ^ Including any conventional clasps, rests, and teeth. Note: • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted procedures are available at certain participating dentists usual fee less 25%. Visit HumanaDental.com to find a participating dentist who offers the discount on non-covered services. • When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional $50 per unit. • If you break your appointment with your dentist without 24-hour advance notice, you will be subject to your dentist’s broken appointment fee. • Additional exclusions and limitations are listed along with full plan information in your certificate of benefits. 34administered by DentiCare, Inc. (d/b/a CompBenefits) Insured or
Advantage Plus 1S Plan Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental Advantage Plus S plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect. • No deductibles • No claims to file • No need to choose a primary care dentist
Know what your plan covers Attached is a summary of HumanaDental Advantage Plus S plan benefits which are described in detail in your certificate. You can find your certificate at HumanaDental.com or call 1-800-9794760. Here’s what you can expect: •
• •
•
You have the freedom to select any participating dentist. To select a dental provider from our Advantage Plus network, simply visit HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-979-4760. Life without claim forms! With HumanaDental Advantage Plus S plan you pay your dentist directly, when applicable. Your Advantage Plus network dentist will provide all of your dental care and any copayment or discounted charges will be paid at the time of service. Except for emergency care, treatment received out-of-network in not covered. You also receive a 20 percent discount on services not listed on your schedule of benefits when visiting certain participating dentists. Visit HumanaDental.com to find a participating dentist who offers the discount on unlisted services.
Questions? Check out HumanaDental.com Call 1-800-979-4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist.
Check your dental IQ anytime Log on to MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.
Rates EE Only
$18.70
EE + Spouse
$38.26
EE + Child(ren)
$38.88
Family Coverage
$63.90
Dependent Max Age Limit: to Age 26
Choose HumanaDental benefits Be healthy Good oral health means more than just an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so.
35
Advantage Plus 1S Plan Advantage Plus plans are network-based dental plans that emphasize prevention and cost containment. Members select any participating general dentist in HumanaDental’s Advantage Plus network. Care received from an out-of-network dentist (except emergency care) is not a covered benefit. S plan copayments for listed procedures are applicable only at participating General Dentist. To find a dentist, call 1-800-979-4760 or look on HumanaDental.com. Office visit copay $5/$15 Annual maximum No annual maximum
Summary of services Preventive
Member Pays
Basic
Periodic oral examination
no charge
D1510
Space maintainer—fixed, unilateral (limited to child <14)
$53.00
D0140
Limited oral evaluation—problem focused
no charge
D1515
$70.00
D0145
Oral evaluation for a patient under three years of age and counseling with primary caregiver (limit 1 every 12 months)
Space maintainer—fixed, bilateral (limited to child <14)
no charge
D1520
Space maintainer—fixed, bilateral (limited to child <14)
$66.00
D0150
Comprehensive oral evaluation—new/ established patient (limit 1 every 24 months)
no charge
D1525
Space maintainer—removable, bilateral (limited to child <14)
$91.00
D1550
Recementation of space maintainer
$12.00
D0160
Limited/comprehensive/detailed and extensive oral eval (limit 1 every 12 months)
no charge
D2140
Amalgam—one surface primary or permanent
$24.00
D0170
Re-evaluation—limited problem focused (limit 1 every 12 months)
no charge
D2150
Amalgam—two surfaces primary or permanent**
$31.00
D0180
Comprehensive periodontal eval—new/ established patient (limit 1 every 24 months)
no charge
D2160
Amalgam—three surfaces primary or permanent*
$37.00
D2161 no charge
Amalgam—four/more surfaces primary/ permanent**
$46.00
D0210
X-ray intraoral—complete series (limit 1 every 3 years) X-ray intraoral—periapical, first film (limit 9 every 12 months includes D0230)
D2330 no charge
Resin based composite—one surface, anterior**
$24.00
D0220
D2331
Resin based composite—two surfaces, anterior**
$31.00
D0230
X-ray intraoral—periapical, each additional film (limit 9 every 12 months includes D0220)
no charge
D2332
Resin based composite—three surfaces, anterior**
$38.00
D0240
X-ray intraoral—occlusal film
no charge
D0250
X-ray extraoral, first film
no charge
D2335
Resin based composite —four or more surfaces, involving incisal angle**
$45.00
D0260
X-ray extraoral, each additional film
no charge
D2390
$49.00
Bitewing—single film
no charge
Resin based composite—crown anterior**
D0272aΔ Bitewings—two films
no charge
D2391
Resin based composite—one surface, posterior**
$28.00
D0273aΔ Bitewings—three films
no charge
D2392
Resin based composite—two surfaces, posterior**
$37.00
D2393
Resin based composite—three surfaces, posterior**
$46.00
D2394
Resin based composite—four or more surfaces, posterior**
$56.00
D4341
Periodontal scaling and root planing— per quadrant, four or more teeth (limit 1 per quad every 12 months)
$39.00
D4342
Periodontal scaling and root planing— per quadrant, 1-3 teeth (limit 1 per quad every 12 months)
$21.00
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis (limit 1 every 5 years)
$26.00
aΔ a
D0120
aΔ
D0270
aΔ
D0274
Bitewings—four films
no charge
D0277aΔ Vertical bitewings—7 to 8 films
no charge
D0330
Panoramic film (limit 1 every 3 years)
no charge
D0470
Diagnostic casts
no charge
D1110aΔ Prophylaxis—adult (inclusive of D4910) aΔ
D1120
Prophylaxis—child (inclusive of D4910)
no charge no charge
D1203aΔ Topical application of fluoride—child (for child <16)
no charge
D1206aΔ Topical fluoride varnish (for child <16)
no charge
D1351
Sealant—per tooth (limit 1 per tooth every 12 months for child <14) 36
no charge
Member Pays
Advantage Plus 1S Plan Basic
Member Pays
Member Pays
D2930
$115.00
$20.00
D2931
Crown—prefabricated stainless steel, permanent tooth
$131.00
$26.00
D2932
Crown—prefabricated resin
$142.00
D2940
Sedative filling
$44.00
D2950
Core buildup including any pins
$110.00
D2951
Pin retention—per tooth addition restoration
$23.00
D4910
$23.00
D7111
Extraction coronal remnants deciduous tooth
D7140
Extraction erupted tooth or exposed root
Major
Major Crown—prefabricated stainless steel, primary tooth
Periodontal maintenance (limit 1 every 6 months, inclusive of D1110 and D1120)
Member Pays
D2510b
Inlay—metallic, one surface
$313.00
D2520b
Inlay—metallic, two surfaces
$355.00
D2530b
Inlay—metallic, three or more surfaces
$410.00
D2952
Cast post and core in addition to crown
$168.00
b
Onlay—metallic, two surfaces
$402.00
D2954
D2543
Onlay—metallic, three surfaces
$420.00
Prefabricated post and core in addition to crown
$139.00
b
D2544b
Onlay—metallic, four or more surfaces
$437.00
D3220
Therapeutic pulpotomy
$75.00
D2610b
Inlay—porcelain/ceramic, one surface
$368.00
D3310
Root canal therapy—anterior
$315.00
D2620
Inlay—porcelain/ceramic, two surfaces
$389.00
D3320
Root canal therapy—bicuspid
$385.00
Root canal therapy—molar
$497.00
D2630b
Inlay—porcelain/ceramic, three or more surfaces
D3330
$414.00
D3346
Previous root canal therapy—anterior
$424.00
Onlay—porcelain/ceramic, two surfaces
$403.00
D3347
Previous root canal therapy—bicuspid
$500.00
D3348
Previous root canal therapy—molar
$601.00
D3410
Apicoectomy/periradicular surgery— anterior
$361.00
D3421
Apicoectomy/periradicular surgery— anterior
$394.00
D3425
Apicoectomy/periradicular surgery— anterior
$445.00
D3426
Apicoectomy/periradicular surgery— each addtl root
$148.00
D3430
Retrograde filling—per root
$109.00 $358.00
D2542
b
b
D2642
D2643b
Onlay—porcelain/ceramic, three surfaces
$434.00
D2644b
Onlay—porcelain/ceramic, four or more surfaces
$461.00
D2650b
Inlay—resin based composite, one surface
$242.00
b
Inlay—resin based composite, two surfaces
$288.00
b
D2652
Inlay—resin based composite, three or more surfaces
$303.00
D2662b
Onlay—resin based composite, two surfaces
$263.00
D4210
Gingivectomy/gingivoplasty—four or more teeth, quad
D2663b
Onlay—resin based composite, three surfaces
$310.00
D4211c
Gingivectomy/gingivoplasty—1 to 3 teeth, quad
$153.00
D2664b
Onlay—resin based ccomposite, four or more surfaces
$332.00
D4240c
D2710
Crown—resin based composite, indirect
$187.00
Gingival flap proc—four or more teeth, quad
$421.00
b
D2720b
D4241c
Gingival flap proc—1 to 3 teeth, quad
$217.00
Crown—resin with high noble metal
$461.00
D4249
Clinical crown lengthening—hard tissue
$481.00
D2721b
Crown—resin with predominantly base metal
$432.00
D4260
$680.00
D2722
Crown—resin with noble metal
$441.00
Osseous surgery—four or more teeth, quad
D2740b
D4261
Crown—porcelain/ceramic substrate
$473.00
D2651
b
c
Osseous surgery—1 to 3 teeth, quad
$354.00
c
Complete denture—maxillary
$642.00
c
D5120
Complete denture—mandibular
$642.00
D5130c
Immediate denture—maxillary
$700.00
D5110
Crown—porcelain fused to high noble metal
$466.00
D2751b
Crown—porcelain fused predom base metal
$434.00
D5140
Immediate denture—mandibular
$700.00
D2752b
Crown—porcelain fused to noble metal
$445.00
D5211d
Maxillary partial denture—resin base
$542.00
b
Crown—full cast high noble metal
$450.00
D5212d
Mandibular partial denture—resin base
$629.00
b
D2791
Crown—full cast predom base metal
$426.00
D2792b
Crown—full cast noble metal
$434.00
D5213d
Maxillary partial denture—cast metal— resin base
$709.00
D2910
Recement inlay, onlay or part coverage restoration
$41.00
D5214d
Mandibular partial denture—cast metal— resin base
$709.00
D2920
Recement crown
$42.00
D5410c
Adjust complete denture—maxillary
$35.00
b
D2750
D2790
d
37
Advantage Plus 1S Plan Major
Member Pays
D5411c
Adjust complete denture—mandibular
$35.00
D5421c
Adjust partial denture—maxillary
$35.00
D5422c
Adjust partial denture—mandibular
D5510
Major
Member Pays
D6603
Inlay—cast high noble metal, three or more surfaces
$418.00
$35.00
D6604f
Inlay—cast predom base metal, two surfaces
$372.00
Repair broken complete denture base
$70.00
D6605f
$59.00
Inlay—cast predom base metal, three or more surfaces
$394.00
D5520
Replace missing/broken teeth— complete denture
f
Inlay—cast noble metal, two surfaces
$366.00
D5610
Repair resin denture base
$76.00
f
D5620
Repair cast framework
$82.00
D6607
Inlay—cast noble metal, three or more surfaces
$406.00
D5630
Repair or replace broken clasp
$100.00
D6608f
Onlay—porcelain/ceramic, two surfaces
$386.00
D6609
Onlay—porcelain/ceramic, three or more surfaces
$403.00
D6610f
Onlay—cast high noble metal, two surfaces
$409.00
D6611f
Onlay—cast high noble metal, three or more surfaces
$448.00
f
D6606
f
D5640
Replace broken teeth—per tooth
$64.00
D5650
Add tooth to existing partial denture
$88.00
D5660
Add clasp to existing partial denture
$105.00
D5710e
Rebase complete maxillary denture
$261.00
D5711
Rebase complete mandibular denture
$249.00
D5720e
Rebase maxillary partial denture
$246.00
D6612f
Onlay—cast predom base metal, two surfaces
$407.00
e
Rebase mandibular partial denture
$246.00
e
D6613f
$426.00
D5730
Reline complete maxillary denture
$147.00
Onlay—cast predom base metal, three or more surfaces
D5731e
Reline complete mandibular denture
$147.00
D6614f
Onlay—cast noble metal, two surfaces
$399.00
D5740e
Reline maxillary partial denture
$135.00
D6615f
Onlay—cast noble metal, three or more surfaces
$414.00
f
Crown—resin with high noble metal
$474.00
f
e
D5721
e
D5741
Reline mandibular partial denture
$135.00
D5750e
Reline complete maxillary denture
$196.00
D6721
Crown—resin with predom base metal
$450.00
D5751e
Reline complete mandibular denture
$196.00
D6722f
Crown—resin with noble metal
$458.00
f
e
D5760
D6720
Reline maxillary partial denture
$193.00
D6740
Crown—porcelain/ceramic
$499.00
D5761e
Reline mandibular partial denture
$193.00
D6750f
Tissue conditioning maxillary
$61.00
Crown—porcelain fused to high noble metal
$486.00
D5850 D5851
Tissue conditioning mandibular
$61.00
D6751f
Crown—porcelain fused to predom base metal
$453.00
D6092
Recement implant/abutment supported crown
$42.00
D6752f
Recement implant/abutment supported fixed partial denture
$57.00
D6093 f
Crown—porcelain fused to noble metal
$464.00
f
D6780
Crown—3/4 cast high noble metal
$458.00
D6790f
Crown—full cast high noble metal
$469.00
f
Crown—full cast predom base metal
$445.00
f
Crown—full cast noble metal
$461.00
f
Recement fixed partial denture
$57.00
f
$157.00
D6210
Pontic—cast high noble metal
$431.00
D6211f
Pontic—cast predominantly base metal
$404.00
D6212f
Pontic—cast noble metal
$420.00
f
D6240
Pontic—porcelain fused to high noble metal
$426.00
D6970
Cast post & core addl fix part denture retainer
D6241f
Pontic—porcelain fused predom base metal
$393.00
D6972f
Prefab post & core addl fix part denture retainer
$128.00
f
Pontic—porcelain fused to noble metal
$415.00
f
D6250
Pontic—resin with high noble metal
$420.00
D6973f
Core build up for retainer including any pins
$103.00
D6251f
Pontic—resin with predominantly base metal
$388.00
D7210
Surgical removal—erupted tooth
$108.00
D6252f
D7220
Removal of impacted tooth—soft tissue
$135.00
Pontic—resin with noble metal
$400.00
D6600f
Inlay—porcelain/ceramic, two surfaces
$355.00
D7230
Removal of impacted tooth—partially bony
$179.00
D6601f
Inlay—porcelain/ceramic, three or more surfaces
$373.00
D7240
Removal of impacted tooth—completely bony
$211.00
D6602f
Inlay—cast high noble metal, two surfaces
$380.00
D7241
Remove impacted tooth—completely bony w/comp
$165.00
D6242
38
D6791 D6792 D6930
Advantage Plus 1S Plan Major
Member Pays
D7250
Surgical removal of residual tooth roots
$114.00
D7310
Alveoloplasty in conjunction w/ extractions—per quad
$125.00
D7311
Alveoloplasty in conjunction w/ extractions—1-3 teeth
$97.00
D7320
Alveoloplasty not conjunction w/ extractions—per quad
$181.00
D7321
Alveoloplasty not conjunction w/ extractions—1-3 teeth
$153.00
D7510
Incision and drainage of abscess— intraoral
$120.00
D7520
Incision and drainage of abscess— extraoral
$570.00
D7960
Frenulectomy—separate procedure.
$111.00
D7970
Excision of hyperplastic tissue—per arch
$272.00
D9110
Palliative treatment dental pain— minor procedure
$45.00
D9215
Local anesthesia
D9241
IV conscious sedation/analg—1st 30 minutes
$144.00
D9242
IV conscious sedation/analg—each addl 15 minutes
$60.00
Orthodontics
D8070
Professional consultation by nontreating dentist
$96.00
D9951
Occlusal adjustment—limited
$58.00
D9952
Occlusal adjustment—complete
$326.00
Consultation Evaluation
no charge $35.00
Records/Treatment Planning
$250.00
Orthodontic treatment
$2100.00
Comprehensive Orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases D8080
Consultation
no charge
Evaluation
$35.00
Records/Treatment Planning
$250.00
Orthodontic treatment
$2100.00
Comprehensive Orthodontic treatment of the transitional/adult dentition; Adults 19 years of age and older; Up to 24 months of routine orthodontic treatment for Class I and Class II cases.
no charge
D9310
Member Pays
Comprehensive Orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
D8090
D8680
Consultation
no charge
Evaluation
$35.00
Records/Treatment Planning
$250.00
Orthodontic treatment
$2300.00
Retention
$450.00
a Limit of one every six months b Limit one per tooth every eight years c Limit one every 12 months d Limit one every five years e Limit of one every three years f Limit of one every eight year Note: • Your participating general dentist and participating specialist office visit co-payment amounts, if applicable, are shown on your I.D. card. • Your office visit co-payment is applicable for all dates of service and is in addition to the co-payment amounts listed for covered dental care services. • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted covered dental care services are available at certain participating dentist’s usual fee less 20%. Visit HumanaDental.com to find a participating dentist who offers the discount on unlisted services. • Additional exclusions and limitations are listed along with full plan information in your Certificate of Benefits. Insured or administered by DentiCare, Inc. (d/b/a CompBenefits)
39
HUMANA YOUR BENEFITS PACKAGE
Vision
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 40 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Vision‐ Humana Vision 130 Vision care services Exam with dila on as necessary Re nal imaging 1 Contact lens exam op ons2 Standard contact lens fit and follow‐up Premium contact lens fit and follow‐up Frames3 Standard plas c lenses4 Single vision Bifocal Trifocal Len cular Covered lens op ons4 UV coa ng Tint (solid and gradient) Standard scratch‐resistance Standard polycarbonate ‐ adults Standard polycarbonate ‐ children <19 Standard an ‐reflec ve coa ng Premium an ‐reflec ve coa ng ‐ Tier 1 ‐ Tier 2 ‐ Tier 3 Standard progressive (add‐on to bifocal) Premium progressive ‐ Tier 1 ‐ Tier 2 ‐ Tier 3 ‐ Tier 4 Photochroma c / plas c transi ons Polarized Contact lenses5 (applies to materials only) Conven onal
Disposable Medically necessary
Frequency Examina on Lenses or contact lenses Frame Diabe c Eye Care: care and tes ng for diabe c members Examina on ‐Up to (2) services per year Re nal Imaging ‐Up to (2) services per year Extended Ophthalmoscopy ‐Up to (2) services per year Gonioscopy ‐ Up to (2) services per year Scanning Laser ‐Up to (2) services per year
If you use an IN‐NETWORK provider (Member cost) $10 Up to $39
If you use an OUT‐OF NETWORK provider (Reimbursement) Up to $30 Not covered
Up to $40 10% off retail $130 allowance 20% off balance over $130
Not covered Not covered $65 allowance
$15 $15 $15 $15
Up to $25 Up to $40 Up to $60 Up to $100
$15 $15 $15 $40 $40 $45 Premium an ‐reflec ve coa ngs as follows: $57 $68 80% of charge $15 Premium progressives as follows: $110 $120 $135 $90 copay, 80% of charge less $120 allowance $75 20% off retail
Not covered Not covered Not covered Not covered Not covered Not covered Premium an ‐reflec ve coa ngs as follows: Not covered Not covered Not covered Up to $40 Premium progressives as follows: Not covered Not covered Not covered Not covered Not covered Not covered
$130 allowance, 15% off balance over $130 $130 allowance $0
$104 allowance $104 allowance $200 allowance
Once every 12 months Once every 12 months Once every 24 months
Once every 12 months Once every 12 months Once every 24 months
$0
Up to $77
$0
Up to $50
$0
Up to $15
$0
Up to $15
$0
Up to $33
Op onal benefits 1.
Member costs may exceed $39 with certain providers. Members may contact their par cipa ng provider to determine what costs or discounts are available. Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by par cipa ng provider. Members may contact their par cipa ng provider to determine what costs or discounts are available. 3 Discounts may be available on all frames except when prohibited by the manufacturer. 4 Lens op on costs may vary by provider. Members may contact their par cipa ng provider to determine if listed costs are available. 5 Plan covers contact lenses or frames, but not both. 41 2
Vision Monthly rates* (12 deduc ons per year) Employee
$6.22
Employee + spouse
$12.45
Employee + child(ren)
$11.84
Family
$18.60
This is not a subs tute for a quote. Rates must be approved by Humana Vision underwri ng.
Addi onal plan discounts
Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact their par cipa ng provider to determine what costs or discounts are available. Discount does not apply to EyeMed Provider's professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promo onal offers. Services or materials provided by any other group benefit plan providing vision care may not be covered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes a no‐ discount prac ce. Frame, Lens, & Lens Op on discounts apply only when purchasing a complete pair of eyeglasses. If purchased separately, members receive 20% off the retail price. Members may also receive 15% off retail price or 5% off promo onal price for LASIK or PRK from the US Laser Network, owned and operated by LCA Vision. Since LASIK or PRK vision correc on is an elec ve procedure, performed by specialty trained providers, this discount may not always be available from a provider in your immediate loca on.
Ques ons? Check out Humana.com Call 1‐866‐995‐9316 seven days a week: 8 a.m. to 6 p.m. Eastern Time Monday through Saturday and 11 a.m. to 8 p.m. Sunday.
Limita ons and Exclusions: In addi on to the limita ons and exclusions listed in your "Vision Benefits" sec on, this policy does not provide benefits for the following: 1. Any expenses incurred while you qualify for any worker's compensa on or occupa onal disease act or law, whether or not you applied for coverage. 2. Services: That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law; Furnished by, or payable under, any plan or law through any government or any poli cal subdivision (this does not include Medicare or Medicaid); or Furnished by any U.S. government‐owned or operated hospital/ins tu on/ agency for any service connected with sickness or bodily injury. 3. Any loss caused or contributed by: War or any act of war, whether declared or not; Any act of interna onal armed conflict; or Any conflict involving armed forces of any interna onal authority. 4. Any expense arising from the comple on of forms.
42
5. Your failure to keep an appointment. 6. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthe st. 7. Prescrip on drugs or pre‐medica ons, whether dispensed or prescribed. 8. Any service not specifically listed in the Schedule of Benefits. 9. Any service that we determine: Is not a visual necessity; Does not offer a favorable prognosis; Does not have uniform professional endorsement; or Is deemed to be experimental or inves ga onal in nature. 10. Orthop c or vision training. 11. Subnormal vision aids and associated tes ng. 12. Aniseikonic lenses. 13. Any service we consider cosme c. 14. Any expense incurred before your effec ve date or a er the date your coverage under this policy terminates. 15. Services provided by someone who ordinarily lives in your home or who is a family member. 16. Charges exceeding the reimbursement limit for the service. 17. Treatment resul ng from any inten onally self‐inflicted injury or bodily illness. 18. Plano lenses. 19. Medical or surgical treatment of eye, eyes, or suppor ng structures. 20. Replacement of lenses or frames furnished under this plan which are lost or broken, unless otherwise available under the plan. 21. Any examina on or material required by an Employer as a condi on of employment. 22. Non‐prescrip on sunglasses. 23. Two pair of glasses in lieu of bifocals. 24. Services or materials provided by any other group benefit plans providing vision care. 25. Certain name brands when manufacturer imposes no discount. 26. Correc ve vision treatment of an experimental nature. 27. Solu ons and/or cleaning products for glasses or contact lenses. 28. Pathological treatment. 29. Non‐prescrip on items. 30. Costs associated with securing materials. 31. Pre‐ and Post‐opera ve services. 32. Orthokeratology. 33. Rou ne maintenance of materials. 34. Refi ng or change in lens design a er ini al fi ng, unless specifically allowed elsewhere in the cer ficate. 35. Ar s cally painted lenses. Humana Vision products insured by Humana Insurance Company, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc. or Humana Insurance Company of New York. This is not a complete disclosure of the plan qualifica ons and limita ons. Specific limita ons and exclusions as contained in the Regulatory and Technical Informa on Guide will be provided by the agent. Please review this informa on before applying for coverage. NOTICE: Your actual expenses for covered services may exceed the stated cost or reimbursement amount because actual provider charges may not be used to determine insurer and member payment obliga ons. Policy Number: TX‐70148‐019/15et.al.
Vision Important! At Humana, it is important you are treated fairly. Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, na onal origin, age, disability, sex, sexual orienta on, gender, gender iden ty, ancestry, marital status, or religion. Discrimina on is against the law. Humana and its subsidiaries comply with applicable Federal Civil Rights laws. If you believe that you have been discriminated against by Humana or its subsidiaries, there are ways to get help. You may file a complaint, also known as a grievance: Discrimina on Grievances, P.O. Box 14618, Lexington, KY 40512‐4618 If you need help filing a grievance, call 1‐877‐320‐1235 or if you use a TTY, call 711. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through their Complaint Portal, available at h ps://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, 1‐800‐368‐1019, 800‐537‐7697 (TDD). Complaint forms are available at h ps://www.hhs.gov/ocr/office/ file/index.html. California residents: You may also call California Department of Insurance toll‐free hotline number: 1‐800‐927‐HELP (4357), to file a grievance. Auxiliary aids and services, free of charge, are available to you. 1‐877‐320‐1235 (TTY: 711) Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote interpreta on, and wri en informa on in other formats to people with disabili es when such auxiliary aids and services are necessary to ensure an equal opportunity to par cipate
43
THE HARTFORD YOUR BENEFITS PACKAGE
Disability
About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.
34.6 months is the duration of the average disability claim.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 44 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Long Term Disability BENEFIT HIGHLIGHTS FOR: FORT WORTH INDEPENDENT SCHOOL DISTRICT
What does “Actively at Work” mean?
Long-Term Disability Insurance pays you a portion of your earnings if you cannot work because of a disabling illness or injury. You have the opportunity to purchase Long-Term Disability Insurance through your employer. This highlight sheet is an overview of your Long-Term Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.
You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.
Why do I need Long-Term Disability Coverage?
How long do I have to wait before I can receive my benefit?
Most accidents and injuries that keep people off the job happen outside the workplace and therefore are not covered by worker’s compensation. When you consider that nearly three in 10 workers entering the workforce today will become disabled before retiring1, it’s protection you won’t want to be without.
You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Long-Term Disability benefit payment. For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day.
What is Long-Term Disability Insurance?
1
Social Security Administration, Fact Sheet 2009.
What is disability? Disability is defined in The Hartford’s* contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings. Once you have been disabled for 24 months, you must be prevented from performing one or more of the essential duties of any occupation and as a result, your current monthly earnings are 66 2/3% or less of your pre-disability earnings.
Am I eligible? You are eligible if you are an active member of the Retirement System of Texas (TRS) who works at least 10 hours per week on a regularly scheduled basis, excluding temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors.
What is an elimination period? The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin.
I already have Disability coverage; do I have to do anything? If you are not changing the amount of your coverage or your elimination period option, you do not have to do anything. If you want to purchase Long-Term Disability insurance for the first time or change your coverage, please be sure to complete the online enrollment, which indicates your election.
What other benefits are included in my disability coverage? •
How much coverage would I have? You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $10,000 that cannot exceed 66 2/3% of your current monthly earnings. Your plan includes a minimum benefit of 20% of your elected benefit. Earnings are defined in The Hartford’s contract with your employer.
When can I enroll? If you choose not to elect coverage during your annual enrollment period, you will not be eligible to elect coverage until the next annual enrollment period without a qualifying change in family status.
When is it effective? Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.
•
Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment. Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse, or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit. The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/ elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services. 45
Long Term Disability •
•
Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services. Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.
How long will my disability payments continue? Can the duration of my benefit be reduced? Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury. Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of either the Premium or Select benefit option.
How long will my disability benefits continue if I elect the Premium benefit option? Premium Option: For the Premium benefit option – the table below applies to disabilities resulting from sickness or injury: Age Disabled Benefits Payable Prior to Age 60 To Age 65 Age 60—64 60 Months To Age 70 Age 65—67 Age 68 and older 24 months
How long will my disability benefits continue if I elect the Select benefit option? Select Option: For the Select benefit option – see the tables below for the applicable benefit duration based on whether your disability is a result of injury or sickness. Schedule for disability caused by injury: Age Disabled Benefits Payable Prior to Age 60 To Age 65 Age 60—64 60 Months To Age 70 Age 65—67 Age 68 and older 24 months Schedule for disability caused by sickness: Age Disabled Benefits Payable Prior to Age 65 5 Years Age 65—69 To Age 70, but not less than 1 year Age 69 and older 1 Year
IMPORTANT DETAILS
Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: • War or act of war (declared or not) • Military service for any country engaged in war or other armed conflict • The commission of, or attempt to commit a felony • An intentionally self-inflicted injury • Any case where your being engaged in an illegal occupation was a contributing cause to your disability • You must be under the regular care of a physician to receive benefits.
Mental Illness, Alcoholism and Substance Abuse •
•
You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 12 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 12 month lifetime limit.
Pre-existing Conditions Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 12 consecutive months just prior to the effective date of this policy, your benefit payment will be limited unless; You have been insured under this policy for 24 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks. Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as: • Social Security Disability Insurance (please see next section for exceptions) • Workers' Compensation • Other employer-based Insurance coverage you may have • Unemployment benefits • Settlements or judgments for income loss Retirement benefits that your employer fully or partially pays for (such as a pension plan.)
Your benefit payments will not be reduced by certain kinds of other income, such as: • Retirement benefits if you were already receiving them before you became disabled • The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement. • Your personal savings, investments, IRAs or Keoghs • Profit-sharing • Most personal disability policies • Social Security increases
This Benefit Highlights Sheet is an overview of the Long-Term Disability Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance coverage. In the event of any difference between the Benefit Highlights Sheet and the Insurance policy, the terms of the Insurance policy apply. Underwritten by: Hartford Life and Accident Insurance Company 200 Hopmeadow Street Simsbury, CT 06089
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Long Term Disability FILE A CLAIM WITH CONFIDENCE Fort Worth Independent School District Policy Number 395332 Your disability program is managed by the Hartford THEHARTFORD.COM/GROUPBENEFITS
The Harford makes it easy to file a claim STEP 1 Know when it’s time to file a claim. If you’re absent from work, we can advise you on when to file your claim. If your absence is scheduled, such as an upcoming hospital stay, simply call us within 30 days of your last day at work. If unscheduled, please call us as soon as possible.
TO FILE A CLAIM 866-278-2655 Policy #395332 If you’re absent from work we can advise you on when to file a claim. If your absence is scheduled, such as an upcoming hospital stay, call within 30 days of your last day of work. If unscheduled, please call us as soon as possible.
STEP 2 Have this information ready. • Name, address and other key identification information. • Name of your department and last full day of active work. • The nature of your claim or leave request. • Your treating physician’s name, address, phone and fax numbers.
STEP 3 Make the call. With your information handy, call The Hartford at 1-866-2782655. You’ll be assisted by a caring professional who’ll take your information, answer your questions and file your claim or process your leave request.
Get Supportive Assistance Even after you claim has been filed, we may be in touch to check your progress, answer questions or obtain additional information from you. Our goal is to offer a smooth and hassle-free experience until you return to work. Feel free to also call us with anything that’s on your mind. We’re here to help.
(Please cut here and keep in your wallet.)
WHEN YOU CALL THE HARTFORD WILL ASK YOU TO PROVIDE: •
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Name, address and other key identification information. Name of your department and last full day of active work. The nature of your claim or leave request. Your treating physician’s name, address, and phone and fax numbers. This card is not proof of insurance.
Relax and Stay Positive You have the assurance of our knowledge, experience and understanding of what you are going through. We’re with you all the way, so you can receive the benefits you qualify for and get back to your life.
Quick Facts The Hartford’s goal is to help get you through your time away from work with dignity and assist you in any way we can. Keep the card below in a safe place for future use. We’ll be there when you need us. The Hartford® is the Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent. The policy number is 395332. CA19060003722481 5445 NS 03/18 © 2018 The Hartford Financial Services Group, Inc. All rights reserved.
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Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 48 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $5.64 $8.46 $11.28 $14.10 $16.92 $19.74 $22.56 $25.38 $28.20 $31.02 $33.84 $36.66 $39.48 $42.30 $45.12 $47.94 $50.76 $53.58 $56.40 $59.22 $62.04 $64.86 $67.68 $70.50 $73.32 $76.14 $78.96 $81.78 $84.60 $87.42 $90.24 $93.06 $95.88 $98.70 $101.52 $104.34 $107.16 $109.98 $112.80 $115.62 $118.44 $121.26 $124.08 $126.90 $129.72 $132.54 $135.36 $138.18 $141.00 $143.82
Ages 30-34 $6.72 $10.08 $13.44 $16.80 $20.16 $23.52 $26.88 $30.24 $33.60 $36.96 $40.32 $43.68 $47.04 $50.40 $53.76 $57.12 $60.48 $63.84 $67.20 $70.56 $73.92 $77.28 $80.64 $84.00 $87.36 $90.72 $94.08 $97.44 $100.80 $104.16 $107.52 $110.88 $114.24 $117.60 $120.96 $124.32 $127.68 $131.04 $134.40 $137.76 $141.12 $144.48 $147.84 $151.20 $154.56 $157.92 $161.28 $164.64 $168.00 $171.36
Ages 35-39 $8.14 $12.21 $16.28 $20.35 $24.42 $28.49 $32.56 $36.63 $40.70 $44.77 $48.84 $52.91 $56.98 $61.05 $65.12 $69.19 $73.26 $77.33 $81.40 $85.47 $89.54 $93.61 $97.68 $101.75 $105.82 $109.89 $113.96 $118.03 $122.10 $126.17 $130.24 $134.31 $138.38 $142.45 $146.52 $150.59 $154.66 $158.73 $162.80 $166.87 $170.94 $175.01 $179.08 $183.15 $187.22 $191.29 $195.36 $199.43 $203.50 $207.57
Ages 40-44 $8.98 $13.47 $17.96 $22.45 $26.94 $31.43 $35.92 $40.41 $44.90 $49.39 $53.88 $58.37 $62.86 $67.35 $71.84 $76.33 $80.82 $85.31 $89.80 $94.29 $98.78 $103.27 $107.76 $112.25 $116.74 $121.23 $125.72 $130.21 $134.70 $139.19 $143.68 $148.17 $152.66 $157.15 $161.64 $166.13 $170.62 $175.11 $179.60 $184.09 $188.58 $193.07 $197.56 $202.05 $206.54 $211.03 $215.52 $220.01 $224.50 $228.99
Ages 45-49 $10.36 $15.54 $20.72 $25.90 $31.08 $36.26 $41.44 $46.62 $51.80 $56.98 $62.16 $67.34 $72.52 $77.70 $82.88 $88.06 $93.24 $98.42 $103.60 $108.78 $113.96 $119.14 $124.32 $129.50 $134.68 $139.86 $145.04 $150.22 $155.40 $160.58 $165.76 $170.94 $176.12 $181.30 $186.48 $191.66 $196.84 $202.02 $207.20 $212.38 $217.56 $222.74 $227.92 $233.10 $238.28 $243.46 $248.64 $253.82 $259.00 $264.18
Ages 50-54 $12.94 $19.41 $25.88 $32.35 $38.82 $45.29 $51.76 $58.23 $64.70 $71.17 $77.64 $84.11 $90.58 $97.05 $103.52 $109.99 $116.46 $122.93 $129.40 $135.87 $142.34 $148.81 $155.28 $161.75 $168.22 $174.69 $181.16 $187.63 $194.10 $200.57 $207.04 $213.51 $219.98 $226.45 $232.92 $239.39 $245.86 $252.33 $258.80 $265.27 $271.74 $278.21 $284.68 $291.15 $297.62 $304.09 $310.56 $317.03 $323.50 $329.97
Ages 55-59 $12.98 $19.47 $25.96 $32.45 $38.94 $45.43 $51.92 $58.41 $64.90 $71.39 $77.88 $84.37 $90.86 $97.35 $103.84 $110.33 $116.82 $123.31 $129.80 $136.29 $142.78 $149.27 $155.76 $162.25 $168.74 $175.23 $181.72 $188.21 $194.70 $201.19 $207.68 $214.17 $220.66 $227.15 $233.64 $240.13 $246.62 $253.11 $259.60 $266.09 $272.58 $279.07 $285.56 $292.05 $298.54 $305.03 $311.52 $318.01 $324.50 $330.99
Ages 60+ $12.36 $18.54 $24.72 $30.90 $37.08 $43.26 $49.44 $55.62 $61.80 $67.98 $74.16 $80.34 $86.52 $92.70 $98.88 $105.06 $111.24 $117.42 $123.60 $129.78 $135.96 $142.14 $148.32 $154.50 $160.68 $166.86 $173.04 $179.22 $185.40 $191.58 $197.76 $203.94 $210.12 $216.30 $222.48 $228.66 $234.84 $241.02 $247.20 $253.38 $259.56 $265.74 $271.92 $278.10 $284.28 $290.46 $296.64 $302.82 $309.00 $315.18
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $146.64 $149.46 $152.28 $155.10 $157.92 $160.74 $163.56 $166.38 $169.20 $172.02 $174.84 $177.66 $180.48 $183.30 $186.12 $188.94 $191.76 $194.58 $197.40 $200.22 $203.04 $205.86 $208.68 $211.50 $214.32 $217.14 $219.96 $222.78 $225.60 $228.42 $231.24 $234.06 $236.88 $239.70 $242.52 $245.34 $248.16 $250.98 $253.80 $256.62 $259.44 $262.26 $265.08 $267.90 $270.72 $273.54 $276.36 $279.18 $282.00
Ages 30-34 $174.72 $178.08 $181.44 $184.80 $188.16 $191.52 $194.88 $198.24 $201.60 $204.96 $208.32 $211.68 $215.04 $218.40 $221.76 $225.12 $228.48 $231.84 $235.20 $238.56 $241.92 $245.28 $248.64 $252.00 $255.36 $258.72 $262.08 $265.44 $268.80 $272.16 $275.52 $278.88 $282.24 $285.60 $288.96 $292.32 $295.68 $299.04 $302.40 $305.76 $309.12 $312.48 $315.84 $319.20 $322.56 $325.92 $329.28 $332.64 $336.00
Ages 35-39 $211.64 $215.71 $219.78 $223.85 $227.92 $231.99 $236.06 $240.13 $244.20 $248.27 $252.34 $256.41 $260.48 $264.55 $268.62 $272.69 $276.76 $280.83 $284.90 $288.97 $293.04 $297.11 $301.18 $305.25 $309.32 $313.39 $317.46 $321.53 $325.60 $329.67 $333.74 $337.81 $341.88 $345.95 $350.02 $354.09 $358.16 $362.23 $366.30 $370.37 $374.44 $378.51 $382.58 $386.65 $390.72 $394.79 $398.86 $402.93 $407.00
Ages 40-44 $233.48 $237.97 $242.46 $246.95 $251.44 $255.93 $260.42 $264.91 $269.40 $273.89 $278.38 $282.87 $287.36 $291.85 $296.34 $300.83 $305.32 $309.81 $314.30 $318.79 $323.28 $327.77 $332.26 $336.75 $341.24 $345.73 $350.22 $354.71 $359.20 $363.69 $368.18 $372.67 $377.16 $381.65 $386.14 $390.63 $395.12 $399.61 $404.10 $408.59 $413.08 $417.57 $422.06 $426.55 $431.04 $435.53 $440.02 $444.51 $449.00
Ages 45-49 $269.36 $274.54 $279.72 $284.90 $290.08 $295.26 $300.44 $305.62 $310.80 $315.98 $321.16 $326.34 $331.52 $336.70 $341.88 $347.06 $352.24 $357.42 $362.60 $367.78 $372.96 $378.14 $383.32 $388.50 $393.68 $398.86 $404.04 $409.22 $414.40 $419.58 $424.76 $429.94 $435.12 $440.30 $445.48 $450.66 $455.84 $461.02 $466.20 $471.38 $476.56 $481.74 $486.92 $492.10 $497.28 $502.46 $507.64 $512.82 $518.00
Ages 50-54 $336.44 $342.91 $349.38 $355.85 $362.32 $368.79 $375.26 $381.73 $388.20 $394.67 $401.14 $407.61 $414.08 $420.55 $427.02 $433.49 $439.96 $446.43 $452.90 $459.37 $465.84 $472.31 $478.78 $485.25 $491.72 $498.19 $504.66 $511.13 $517.60 $524.07 $530.54 $537.01 $543.48 $549.95 $556.42 $562.89 $569.36 $575.83 $582.30 $588.77 $595.24 $601.71 $608.18 $614.65 $621.12 $627.59 $634.06 $640.53 $647.00
Ages 55-59 $337.48 $343.97 $350.46 $356.95 $363.44 $369.93 $376.42 $382.91 $389.40 $395.89 $402.38 $408.87 $415.36 $421.85 $428.34 $434.83 $441.32 $447.81 $454.30 $460.79 $467.28 $473.77 $480.26 $486.75 $493.24 $499.73 $506.22 $512.71 $519.20 $525.69 $532.18 $538.67 $545.16 $551.65 $558.14 $564.63 $571.12 $577.61 $584.10 $590.59 $597.08 $603.57 $610.06 $616.55 $623.04 $629.53 $636.02 $642.51 $649.00
Ages 60+ $321.36 $327.54 $333.72 $339.90 $346.08 $352.26 $358.44 $364.62 $370.80 $376.98 $383.16 $389.34 $395.52 $401.70 $407.88 $414.06 $420.24 $426.42 $432.60 $438.78 $444.96 $451.14 $457.32 $463.50 $469.68 $475.86 $482.04 $488.22 $494.40 $500.58 $506.76 $512.94 $519.12 $525.30 $531.48 $537.66 $543.84 $550.02 $556.20 $562.38 $568.56 $574.74 $580.92 $587.10 $593.28 $599.46 $605.64 $611.82 49 $618.00
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 50 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $4.86 $7.29 $9.72 $12.15 $14.58 $17.01 $19.44 $21.87 $24.30 $26.73 $29.16 $31.59 $34.02 $36.45 $38.88 $41.31 $43.74 $46.17 $48.60 $51.03 $53.46 $55.89 $58.32 $60.75 $63.18 $65.61 $68.04 $70.47 $72.90 $75.33 $77.76 $80.19 $82.62 $85.05 $87.48 $89.91 $92.34 $94.77 $97.20 $99.63 $102.06 $104.49 $106.92 $109.35 $111.78 $114.21 $116.64 $119.07 $121.50 $123.93
Ages 30-34 $5.78 $8.67 $11.56 $14.45 $17.34 $20.23 $23.12 $26.01 $28.90 $31.79 $34.68 $37.57 $40.46 $43.35 $46.24 $49.13 $52.02 $54.91 $57.80 $60.69 $63.58 $66.47 $69.36 $72.25 $75.14 $78.03 $80.92 $83.81 $86.70 $89.59 $92.48 $95.37 $98.26 $101.15 $104.04 $106.93 $109.82 $112.71 $115.60 $118.49 $121.38 $124.27 $127.16 $130.05 $132.94 $135.83 $138.72 $141.61 $144.50 $147.39
Ages 35-39 $7.02 $10.53 $14.04 $17.55 $21.06 $24.57 $28.08 $31.59 $35.10 $38.61 $42.12 $45.63 $49.14 $52.65 $56.16 $59.67 $63.18 $66.69 $70.20 $73.71 $77.22 $80.73 $84.24 $87.75 $91.26 $94.77 $98.28 $101.79 $105.30 $108.81 $112.32 $115.83 $119.34 $122.85 $126.36 $129.87 $133.38 $136.89 $140.40 $143.91 $147.42 $150.93 $154.44 $157.95 $161.46 $164.97 $168.48 $171.99 $175.50 $179.01
Ages 40-44 $7.82 $11.73 $15.64 $19.55 $23.46 $27.37 $31.28 $35.19 $39.10 $43.01 $46.92 $50.83 $54.74 $58.65 $62.56 $66.47 $70.38 $74.29 $78.20 $82.11 $86.02 $89.93 $93.84 $97.75 $101.66 $105.57 $109.48 $113.39 $117.30 $121.21 $125.12 $129.03 $132.94 $136.85 $140.76 $144.67 $148.58 $152.49 $156.40 $160.31 $164.22 $168.13 $172.04 $175.95 $179.86 $183.77 $187.68 $191.59 $195.50 $199.41
Ages 45-49 $9.04 $13.56 $18.08 $22.60 $27.12 $31.64 $36.16 $40.68 $45.20 $49.72 $54.24 $58.76 $63.28 $67.80 $72.32 $76.84 $81.36 $85.88 $90.40 $94.92 $99.44 $103.96 $108.48 $113.00 $117.52 $122.04 $126.56 $131.08 $135.60 $140.12 $144.64 $149.16 $153.68 $158.20 $162.72 $167.24 $171.76 $176.28 $180.80 $185.32 $189.84 $194.36 $198.88 $203.40 $207.92 $212.44 $216.96 $221.48 $226.00 $230.52
Ages 50-54 $11.30 $16.95 $22.60 $28.25 $33.90 $39.55 $45.20 $50.85 $56.50 $62.15 $67.80 $73.45 $79.10 $84.75 $90.40 $96.05 $101.70 $107.35 $113.00 $118.65 $124.30 $129.95 $135.60 $141.25 $146.90 $152.55 $158.20 $163.85 $169.50 $175.15 $180.80 $186.45 $192.10 $197.75 $203.40 $209.05 $214.70 $220.35 $226.00 $231.65 $237.30 $242.95 $248.60 $254.25 $259.90 $265.55 $271.20 $276.85 $282.50 $288.15
Ages 55-59 $11.22 $16.83 $22.44 $28.05 $33.66 $39.27 $44.88 $50.49 $56.10 $61.71 $67.32 $72.93 $78.54 $84.15 $89.76 $95.37 $100.98 $106.59 $112.20 $117.81 $123.42 $129.03 $134.64 $140.25 $145.86 $151.47 $157.08 $162.69 $168.30 $173.91 $179.52 $185.13 $190.74 $196.35 $201.96 $207.57 $213.18 $218.79 $224.40 $230.01 $235.62 $241.23 $246.84 $252.45 $258.06 $263.67 $269.28 $274.89 $280.50 $286.11
Ages 60+ $10.42 $15.63 $20.84 $26.05 $31.26 $36.47 $41.68 $46.89 $52.10 $57.31 $62.52 $67.73 $72.94 $78.15 $83.36 $88.57 $93.78 $98.99 $104.20 $109.41 $114.62 $119.83 $125.04 $130.25 $135.46 $140.67 $145.88 $151.09 $156.30 $161.51 $166.72 $171.93 $177.14 $182.35 $187.56 $192.77 $197.98 $203.19 $208.40 $213.61 $218.82 $224.03 $229.24 $234.45 $239.66 $244.87 $250.08 $255.29 $260.50 $265.71
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $126.36 $128.79 $131.22 $133.65 $136.08 $138.51 $140.94 $143.37 $145.80 $148.23 $150.66 $153.09 $155.52 $157.95 $160.38 $162.81 $165.24 $167.67 $170.10 $172.53 $174.96 $177.39 $179.82 $182.25 $184.68 $187.11 $189.54 $191.97 $194.40 $196.83 $199.26 $201.69 $204.12 $206.55 $208.98 $211.41 $213.84 $216.27 $218.70 $221.13 $223.56 $225.99 $228.42 $230.85 $233.28 $235.71 $238.14 $240.57 $243.00
Ages 30-34 $150.28 $153.17 $156.06 $158.95 $161.84 $164.73 $167.62 $170.51 $173.40 $176.29 $179.18 $182.07 $184.96 $187.85 $190.74 $193.63 $196.52 $199.41 $202.30 $205.19 $208.08 $210.97 $213.86 $216.75 $219.64 $222.53 $225.42 $228.31 $231.20 $234.09 $236.98 $239.87 $242.76 $245.65 $248.54 $251.43 $254.32 $257.21 $260.10 $262.99 $265.88 $268.77 $271.66 $274.55 $277.44 $280.33 $283.22 $286.11 $289.00
Ages 35-39 $182.52 $186.03 $189.54 $193.05 $196.56 $200.07 $203.58 $207.09 $210.60 $214.11 $217.62 $221.13 $224.64 $228.15 $231.66 $235.17 $238.68 $242.19 $245.70 $249.21 $252.72 $256.23 $259.74 $263.25 $266.76 $270.27 $273.78 $277.29 $280.80 $284.31 $287.82 $291.33 $294.84 $298.35 $301.86 $305.37 $308.88 $312.39 $315.90 $319.41 $322.92 $326.43 $329.94 $333.45 $336.96 $340.47 $343.98 $347.49 $351.00
Ages 40-44 $203.32 $207.23 $211.14 $215.05 $218.96 $222.87 $226.78 $230.69 $234.60 $238.51 $242.42 $246.33 $250.24 $254.15 $258.06 $261.97 $265.88 $269.79 $273.70 $277.61 $281.52 $285.43 $289.34 $293.25 $297.16 $301.07 $304.98 $308.89 $312.80 $316.71 $320.62 $324.53 $328.44 $332.35 $336.26 $340.17 $344.08 $347.99 $351.90 $355.81 $359.72 $363.63 $367.54 $371.45 $375.36 $379.27 $383.18 $387.09 $391.00
Ages 45-49 $235.04 $239.56 $244.08 $248.60 $253.12 $257.64 $262.16 $266.68 $271.20 $275.72 $280.24 $284.76 $289.28 $293.80 $298.32 $302.84 $307.36 $311.88 $316.40 $320.92 $325.44 $329.96 $334.48 $339.00 $343.52 $348.04 $352.56 $357.08 $361.60 $366.12 $370.64 $375.16 $379.68 $384.20 $388.72 $393.24 $397.76 $402.28 $406.80 $411.32 $415.84 $420.36 $424.88 $429.40 $433.92 $438.44 $442.96 $447.48 $452.00
Ages 50-54 $293.80 $299.45 $305.10 $310.75 $316.40 $322.05 $327.70 $333.35 $339.00 $344.65 $350.30 $355.95 $361.60 $367.25 $372.90 $378.55 $384.20 $389.85 $395.50 $401.15 $406.80 $412.45 $418.10 $423.75 $429.40 $435.05 $440.70 $446.35 $452.00 $457.65 $463.30 $468.95 $474.60 $480.25 $485.90 $491.55 $497.20 $502.85 $508.50 $514.15 $519.80 $525.45 $531.10 $536.75 $542.40 $548.05 $553.70 $559.35 $565.00
Ages 55-59 $291.72 $297.33 $302.94 $308.55 $314.16 $319.77 $325.38 $330.99 $336.60 $342.21 $347.82 $353.43 $359.04 $364.65 $370.26 $375.87 $381.48 $387.09 $392.70 $398.31 $403.92 $409.53 $415.14 $420.75 $426.36 $431.97 $437.58 $443.19 $448.80 $454.41 $460.02 $465.63 $471.24 $476.85 $482.46 $488.07 $493.68 $499.29 $504.90 $510.51 $516.12 $521.73 $527.34 $532.95 $538.56 $544.17 $549.78 $555.39 $561.00
Ages 60+ $270.92 $276.13 $281.34 $286.55 $291.76 $296.97 $302.18 $307.39 $312.60 $317.81 $323.02 $328.23 $333.44 $338.65 $343.86 $349.07 $354.28 $359.49 $364.70 $369.91 $375.12 $380.33 $385.54 $390.75 $395.96 $401.17 $406.38 $411.59 $416.80 $422.01 $427.22 $432.43 $437.64 $442.85 $448.06 $453.27 $458.48 $463.69 $468.90 $474.11 $479.32 $484.53 $489.74 $494.95 $500.16 $505.37 $510.58 $515.79 51 $521.00
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 52 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $4.06 $6.09 $8.12 $10.15 $12.18 $14.21 $16.24 $18.27 $20.30 $22.33 $24.36 $26.39 $28.42 $30.45 $32.48 $34.51 $36.54 $38.57 $40.60 $42.63 $44.66 $46.69 $48.72 $50.75 $52.78 $54.81 $56.84 $58.87 $60.90 $62.93 $64.96 $66.99 $69.02 $71.05 $73.08 $75.11 $77.14 $79.17 $81.20 $83.23 $85.26 $87.29 $89.32 $91.35 $93.38 $95.41 $97.44 $99.47 $101.50 $103.53
Ages 30-34 $4.82 $7.23 $9.64 $12.05 $14.46 $16.87 $19.28 $21.69 $24.10 $26.51 $28.92 $31.33 $33.74 $36.15 $38.56 $40.97 $43.38 $45.79 $48.20 $50.61 $53.02 $55.43 $57.84 $60.25 $62.66 $65.07 $67.48 $69.89 $72.30 $74.71 $77.12 $79.53 $81.94 $84.35 $86.76 $89.17 $91.58 $93.99 $96.40 $98.81 $101.22 $103.63 $106.04 $108.45 $110.86 $113.27 $115.68 $118.09 $120.50 $122.91
Ages 35-39 $5.90 $8.85 $11.80 $14.75 $17.70 $20.65 $23.60 $26.55 $29.50 $32.45 $35.40 $38.35 $41.30 $44.25 $47.20 $50.15 $53.10 $56.05 $59.00 $61.95 $64.90 $67.85 $70.80 $73.75 $76.70 $79.65 $82.60 $85.55 $88.50 $91.45 $94.40 $97.35 $100.30 $103.25 $106.20 $109.15 $112.10 $115.05 $118.00 $120.95 $123.90 $126.85 $129.80 $132.75 $135.70 $138.65 $141.60 $144.55 $147.50 $150.45
Ages 40-44 $6.66 $9.99 $13.32 $16.65 $19.98 $23.31 $26.64 $29.97 $33.30 $36.63 $39.96 $43.29 $46.62 $49.95 $53.28 $56.61 $59.94 $63.27 $66.60 $69.93 $73.26 $76.59 $79.92 $83.25 $86.58 $89.91 $93.24 $96.57 $99.90 $103.23 $106.56 $109.89 $113.22 $116.55 $119.88 $123.21 $126.54 $129.87 $133.20 $136.53 $139.86 $143.19 $146.52 $149.85 $153.18 $156.51 $159.84 $163.17 $166.50 $169.83
Ages 45-49 $7.70 $11.55 $15.40 $19.25 $23.10 $26.95 $30.80 $34.65 $38.50 $42.35 $46.20 $50.05 $53.90 $57.75 $61.60 $65.45 $69.30 $73.15 $77.00 $80.85 $84.70 $88.55 $92.40 $96.25 $100.10 $103.95 $107.80 $111.65 $115.50 $119.35 $123.20 $127.05 $130.90 $134.75 $138.60 $142.45 $146.30 $150.15 $154.00 $157.85 $161.70 $165.55 $169.40 $173.25 $177.10 $180.95 $184.80 $188.65 $192.50 $196.35
Ages 50-54 $9.60 $14.40 $19.20 $24.00 $28.80 $33.60 $38.40 $43.20 $48.00 $52.80 $57.60 $62.40 $67.20 $72.00 $76.80 $81.60 $86.40 $91.20 $96.00 $100.80 $105.60 $110.40 $115.20 $120.00 $124.80 $129.60 $134.40 $139.20 $144.00 $148.80 $153.60 $158.40 $163.20 $168.00 $172.80 $177.60 $182.40 $187.20 $192.00 $196.80 $201.60 $206.40 $211.20 $216.00 $220.80 $225.60 $230.40 $235.20 $240.00 $244.80
Ages 55-59 $9.46 $14.19 $18.92 $23.65 $28.38 $33.11 $37.84 $42.57 $47.30 $52.03 $56.76 $61.49 $66.22 $70.95 $75.68 $80.41 $85.14 $89.87 $94.60 $99.33 $104.06 $108.79 $113.52 $118.25 $122.98 $127.71 $132.44 $137.17 $141.90 $146.63 $151.36 $156.09 $160.82 $165.55 $170.28 $175.01 $179.74 $184.47 $189.20 $193.93 $198.66 $203.39 $208.12 $212.85 $217.58 $222.31 $227.04 $231.77 $236.50 $241.23
Ages 60+ $8.46 $12.69 $16.92 $21.15 $25.38 $29.61 $33.84 $38.07 $42.30 $46.53 $50.76 $54.99 $59.22 $63.45 $67.68 $71.91 $76.14 $80.37 $84.60 $88.83 $93.06 $97.29 $101.52 $105.75 $109.98 $114.21 $118.44 $122.67 $126.90 $131.13 $135.36 $139.59 $143.82 $148.05 $152.28 $156.51 $160.74 $164.97 $169.20 $173.43 $177.66 $181.89 $186.12 $190.35 $194.58 $198.81 $203.04 $207.27 $211.50 $215.73
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $105.56 $107.59 $109.62 $111.65 $113.68 $115.71 $117.74 $119.77 $121.80 $123.83 $125.86 $127.89 $129.92 $131.95 $133.98 $136.01 $138.04 $140.07 $142.10 $144.13 $146.16 $148.19 $150.22 $152.25 $154.28 $156.31 $158.34 $160.37 $162.40 $164.43 $166.46 $168.49 $170.52 $172.55 $174.58 $176.61 $178.64 $180.67 $182.70 $184.73 $186.76 $188.79 $190.82 $192.85 $194.88 $196.91 $198.94 $200.97 $203.00
Ages 30-34 $125.32 $127.73 $130.14 $132.55 $134.96 $137.37 $139.78 $142.19 $144.60 $147.01 $149.42 $151.83 $154.24 $156.65 $159.06 $161.47 $163.88 $166.29 $168.70 $171.11 $173.52 $175.93 $178.34 $180.75 $183.16 $185.57 $187.98 $190.39 $192.80 $195.21 $197.62 $200.03 $202.44 $204.85 $207.26 $209.67 $212.08 $214.49 $216.90 $219.31 $221.72 $224.13 $226.54 $228.95 $231.36 $233.77 $236.18 $238.59 $241.00
Ages 35-39 $153.40 $156.35 $159.30 $162.25 $165.20 $168.15 $171.10 $174.05 $177.00 $179.95 $182.90 $185.85 $188.80 $191.75 $194.70 $197.65 $200.60 $203.55 $206.50 $209.45 $212.40 $215.35 $218.30 $221.25 $224.20 $227.15 $230.10 $233.05 $236.00 $238.95 $241.90 $244.85 $247.80 $250.75 $253.70 $256.65 $259.60 $262.55 $265.50 $268.45 $271.40 $274.35 $277.30 $280.25 $283.20 $286.15 $289.10 $292.05 $295.00
Ages 40-44 $173.16 $176.49 $179.82 $183.15 $186.48 $189.81 $193.14 $196.47 $199.80 $203.13 $206.46 $209.79 $213.12 $216.45 $219.78 $223.11 $226.44 $229.77 $233.10 $236.43 $239.76 $243.09 $246.42 $249.75 $253.08 $256.41 $259.74 $263.07 $266.40 $269.73 $273.06 $276.39 $279.72 $283.05 $286.38 $289.71 $293.04 $296.37 $299.70 $303.03 $306.36 $309.69 $313.02 $316.35 $319.68 $323.01 $326.34 $329.67 $333.00
Ages 45-49 $200.20 $204.05 $207.90 $211.75 $215.60 $219.45 $223.30 $227.15 $231.00 $234.85 $238.70 $242.55 $246.40 $250.25 $254.10 $257.95 $261.80 $265.65 $269.50 $273.35 $277.20 $281.05 $284.90 $288.75 $292.60 $296.45 $300.30 $304.15 $308.00 $311.85 $315.70 $319.55 $323.40 $327.25 $331.10 $334.95 $338.80 $342.65 $346.50 $350.35 $354.20 $358.05 $361.90 $365.75 $369.60 $373.45 $377.30 $381.15 $385.00
Ages 50-54 $249.60 $254.40 $259.20 $264.00 $268.80 $273.60 $278.40 $283.20 $288.00 $292.80 $297.60 $302.40 $307.20 $312.00 $316.80 $321.60 $326.40 $331.20 $336.00 $340.80 $345.60 $350.40 $355.20 $360.00 $364.80 $369.60 $374.40 $379.20 $384.00 $388.80 $393.60 $398.40 $403.20 $408.00 $412.80 $417.60 $422.40 $427.20 $432.00 $436.80 $441.60 $446.40 $451.20 $456.00 $460.80 $465.60 $470.40 $475.20 $480.00
Ages 55-59 $245.96 $250.69 $255.42 $260.15 $264.88 $269.61 $274.34 $279.07 $283.80 $288.53 $293.26 $297.99 $302.72 $307.45 $312.18 $316.91 $321.64 $326.37 $331.10 $335.83 $340.56 $345.29 $350.02 $354.75 $359.48 $364.21 $368.94 $373.67 $378.40 $383.13 $387.86 $392.59 $397.32 $402.05 $406.78 $411.51 $416.24 $420.97 $425.70 $430.43 $435.16 $439.89 $444.62 $449.35 $454.08 $458.81 $463.54 $468.27 $473.00
Ages 60+ $219.96 $224.19 $228.42 $232.65 $236.88 $241.11 $245.34 $249.57 $253.80 $258.03 $262.26 $266.49 $270.72 $274.95 $279.18 $283.41 $287.64 $291.87 $296.10 $300.33 $304.56 $308.79 $313.02 $317.25 $321.48 $325.71 $329.94 $334.17 $338.40 $342.63 $346.86 $351.09 $355.32 $359.55 $363.78 $368.01 $372.24 $376.47 $380.70 $384.93 $389.16 $393.39 $397.62 $401.85 $406.08 $410.31 $414.54 $418.77 53 $423.00
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 54 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $3.52 $5.28 $7.04 $8.80 $10.56 $12.32 $14.08 $15.84 $17.60 $19.36 $21.12 $22.88 $24.64 $26.40 $28.16 $29.92 $31.68 $33.44 $35.20 $36.96 $38.72 $40.48 $42.24 $44.00 $45.76 $47.52 $49.28 $51.04 $52.80 $54.56 $56.32 $58.08 $59.84 $61.60 $63.36 $65.12 $66.88 $68.64 $70.40 $72.16 $73.92 $75.68 $77.44 $79.20 $80.96 $82.72 $84.48 $86.24 $88.00 $89.76
90 Day Elimination Period – Accident and Sickness to Age 65 Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $4.18 $5.08 $5.78 $6.74 $8.38 $8.26 $6.27 $7.62 $8.67 $10.11 $12.57 $12.39 $8.36 $10.16 $11.56 $13.48 $16.76 $16.52 $10.45 $12.70 $14.45 $16.85 $20.95 $20.65 $12.54 $15.24 $17.34 $20.22 $25.14 $24.78 $14.63 $17.78 $20.23 $23.59 $29.33 $28.91 $16.72 $20.32 $23.12 $26.96 $33.52 $33.04 $18.81 $22.86 $26.01 $30.33 $37.71 $37.17 $20.90 $25.40 $28.90 $33.70 $41.90 $41.30 $22.99 $27.94 $31.79 $37.07 $46.09 $45.43 $25.08 $30.48 $34.68 $40.44 $50.28 $49.56 $27.17 $33.02 $37.57 $43.81 $54.47 $53.69 $29.26 $35.56 $40.46 $47.18 $58.66 $57.82 $31.35 $38.10 $43.35 $50.55 $62.85 $61.95 $33.44 $40.64 $46.24 $53.92 $67.04 $66.08 $35.53 $43.18 $49.13 $57.29 $71.23 $70.21 $37.62 $45.72 $52.02 $60.66 $75.42 $74.34 $39.71 $48.26 $54.91 $64.03 $79.61 $78.47 $41.80 $50.80 $57.80 $67.40 $83.80 $82.60 $43.89 $53.34 $60.69 $70.77 $87.99 $86.73 $45.98 $55.88 $63.58 $74.14 $92.18 $90.86 $48.07 $58.42 $66.47 $77.51 $96.37 $94.99 $50.16 $60.96 $69.36 $80.88 $100.56 $99.12 $52.25 $63.50 $72.25 $84.25 $104.75 $103.25 $54.34 $66.04 $75.14 $87.62 $108.94 $107.38 $56.43 $68.58 $78.03 $90.99 $113.13 $111.51 $58.52 $71.12 $80.92 $94.36 $117.32 $115.64 $60.61 $73.66 $83.81 $97.73 $121.51 $119.77 $62.70 $76.20 $86.70 $101.10 $125.70 $123.90 $64.79 $78.74 $89.59 $104.47 $129.89 $128.03 $66.88 $81.28 $92.48 $107.84 $134.08 $132.16 $68.97 $83.82 $95.37 $111.21 $138.27 $136.29 $71.06 $86.36 $98.26 $114.58 $142.46 $140.42 $73.15 $88.90 $101.15 $117.95 $146.65 $144.55 $75.24 $91.44 $104.04 $121.32 $150.84 $148.68 $77.33 $93.98 $106.93 $124.69 $155.03 $152.81 $79.42 $96.52 $109.82 $128.06 $159.22 $156.94 $81.51 $99.06 $112.71 $131.43 $163.41 $161.07 $83.60 $101.60 $115.60 $134.80 $167.60 $165.20 $85.69 $104.14 $118.49 $138.17 $171.79 $169.33 $87.78 $106.68 $121.38 $141.54 $175.98 $173.46 $89.87 $109.22 $124.27 $144.91 $180.17 $177.59 $91.96 $111.76 $127.16 $148.28 $184.36 $181.72 $94.05 $114.30 $130.05 $151.65 $188.55 $185.85 $96.14 $116.84 $132.94 $155.02 $192.74 $189.98 $98.23 $119.38 $135.83 $158.39 $196.93 $194.11 $100.32 $121.92 $138.72 $161.76 $201.12 $198.24 $102.41 $124.46 $141.61 $165.13 $205.31 $202.37 $104.50 $127.00 $144.50 $168.50 $209.50 $206.50 $106.59 $129.54 $147.39 $171.87 $213.69 $210.63
Ages 60+ $7.00 $10.50 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $35.00 $38.50 $42.00 $45.50 $49.00 $52.50 $56.00 $59.50 $63.00 $66.50 $70.00 $73.50 $77.00 $80.50 $84.00 $87.50 $91.00 $94.50 $98.00 $101.50 $105.00 $108.50 $112.00 $115.50 $119.00 $122.50 $126.00 $129.50 $133.00 $136.50 $140.00 $143.50 $147.00 $150.50 $154.00 $157.50 $161.00 $164.50 $168.00 $171.50 $175.00 $178.50
Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $91.52 $93.28 $95.04 $96.80 $98.56 $100.32 $102.08 $103.84 $105.60 $107.36 $109.12 $110.88 $112.64 $114.40 $116.16 $117.92 $119.68 $121.44 $123.20 $124.96 $126.72 $128.48 $130.24 $132.00 $133.76 $135.52 $137.28 $139.04 $140.80 $142.56 $144.32 $146.08 $147.84 $149.60 $151.36 $153.12 $154.88 $156.64 $158.40 $160.16 $161.92 $163.68 $165.44 $167.20 $168.96 $170.72 $172.48 $174.24 $176.00
90 Day Elimination Period – Accident and Sickness to Age 65 Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $108.68 $132.08 $150.28 $175.24 $217.88 $214.76 $110.77 $134.62 $153.17 $178.61 $222.07 $218.89 $112.86 $137.16 $156.06 $181.98 $226.26 $223.02 $114.95 $139.70 $158.95 $185.35 $230.45 $227.15 $117.04 $142.24 $161.84 $188.72 $234.64 $231.28 $119.13 $144.78 $164.73 $192.09 $238.83 $235.41 $121.22 $147.32 $167.62 $195.46 $243.02 $239.54 $123.31 $149.86 $170.51 $198.83 $247.21 $243.67 $125.40 $152.40 $173.40 $202.20 $251.40 $247.80 $127.49 $154.94 $176.29 $205.57 $255.59 $251.93 $129.58 $157.48 $179.18 $208.94 $259.78 $256.06 $131.67 $160.02 $182.07 $212.31 $263.97 $260.19 $133.76 $162.56 $184.96 $215.68 $268.16 $264.32 $135.85 $165.10 $187.85 $219.05 $272.35 $268.45 $137.94 $167.64 $190.74 $222.42 $276.54 $272.58 $140.03 $170.18 $193.63 $225.79 $280.73 $276.71 $142.12 $172.72 $196.52 $229.16 $284.92 $280.84 $144.21 $175.26 $199.41 $232.53 $289.11 $284.97 $146.30 $177.80 $202.30 $235.90 $293.30 $289.10 $148.39 $180.34 $205.19 $239.27 $297.49 $293.23 $150.48 $182.88 $208.08 $242.64 $301.68 $297.36 $152.57 $185.42 $210.97 $246.01 $305.87 $301.49 $154.66 $187.96 $213.86 $249.38 $310.06 $305.62 $156.75 $190.50 $216.75 $252.75 $314.25 $309.75 $158.84 $193.04 $219.64 $256.12 $318.44 $313.88 $160.93 $195.58 $222.53 $259.49 $322.63 $318.01 $163.02 $198.12 $225.42 $262.86 $326.82 $322.14 $165.11 $200.66 $228.31 $266.23 $331.01 $326.27 $167.20 $203.20 $231.20 $269.60 $335.20 $330.40 $169.29 $205.74 $234.09 $272.97 $339.39 $334.53 $171.38 $208.28 $236.98 $276.34 $343.58 $338.66 $173.47 $210.82 $239.87 $279.71 $347.77 $342.79 $175.56 $213.36 $242.76 $283.08 $351.96 $346.92 $177.65 $215.90 $245.65 $286.45 $356.15 $351.05 $179.74 $218.44 $248.54 $289.82 $360.34 $355.18 $181.83 $220.98 $251.43 $293.19 $364.53 $359.31 $183.92 $223.52 $254.32 $296.56 $368.72 $363.44 $186.01 $226.06 $257.21 $299.93 $372.91 $367.57 $188.10 $228.60 $260.10 $303.30 $377.10 $371.70 $190.19 $231.14 $262.99 $306.67 $381.29 $375.83 $192.28 $233.68 $265.88 $310.04 $385.48 $379.96 $194.37 $236.22 $268.77 $313.41 $389.67 $384.09 $196.46 $238.76 $271.66 $316.78 $393.86 $388.22 $198.55 $241.30 $274.55 $320.15 $398.05 $392.35 $200.64 $243.84 $277.44 $323.52 $402.24 $396.48 $202.73 $246.38 $280.33 $326.89 $406.43 $400.61 $204.82 $248.92 $283.22 $330.26 $410.62 $404.74 $206.91 $251.46 $286.11 $333.63 $414.81 $408.87 $209.00 $254.00 $289.00 $337.00 $419.00 $413.00
Ages 60+ $182.00 $185.50 $189.00 $192.50 $196.00 $199.50 $203.00 $206.50 $210.00 $213.50 $217.00 $220.50 $224.00 $227.50 $231.00 $234.50 $238.00 $241.50 $245.00 $248.50 $252.00 $255.50 $259.00 $262.50 $266.00 $269.50 $273.00 $276.50 $280.00 $283.50 $287.00 $290.50 $294.00 $297.50 $301.00 $304.50 $308.00 $311.50 $315.00 $318.50 $322.00 $325.50 $329.00 $332.50 $336.00 $339.50 $343.00 $346.50 55 $350.00
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 56 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $4.44 $6.66 $8.88 $11.10 $13.32 $15.54 $17.76 $19.98 $22.20 $24.42 $26.64 $28.86 $31.08 $33.30 $35.52 $37.74 $39.96 $42.18 $44.40 $46.62 $48.84 $51.06 $53.28 $55.50 $57.72 $59.94 $62.16 $64.38 $66.60 $68.82 $71.04 $73.26 $75.48 $77.70 $79.92 $82.14 $84.36 $86.58 $88.80 $91.02 $93.24 $95.46 $97.68 $99.90 $102.12 $104.34 $106.56 $108.78 $111.00 $113.22
14 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $5.24 $6.34 $6.66 $7.46 $9.34 $10.04 $7.86 $9.51 $9.99 $11.19 $14.01 $15.06 $10.48 $12.68 $13.32 $14.92 $18.68 $20.08 $13.10 $15.85 $16.65 $18.65 $23.35 $25.10 $15.72 $19.02 $19.98 $22.38 $28.02 $30.12 $18.34 $22.19 $23.31 $26.11 $32.69 $35.14 $20.96 $25.36 $26.64 $29.84 $37.36 $40.16 $23.58 $28.53 $29.97 $33.57 $42.03 $45.18 $26.20 $31.70 $33.30 $37.30 $46.70 $50.20 $28.82 $34.87 $36.63 $41.03 $51.37 $55.22 $31.44 $38.04 $39.96 $44.76 $56.04 $60.24 $34.06 $41.21 $43.29 $48.49 $60.71 $65.26 $36.68 $44.38 $46.62 $52.22 $65.38 $70.28 $39.30 $47.55 $49.95 $55.95 $70.05 $75.30 $41.92 $50.72 $53.28 $59.68 $74.72 $80.32 $44.54 $53.89 $56.61 $63.41 $79.39 $85.34 $47.16 $57.06 $59.94 $67.14 $84.06 $90.36 $49.78 $60.23 $63.27 $70.87 $88.73 $95.38 $52.40 $63.40 $66.60 $74.60 $93.40 $100.40 $55.02 $66.57 $69.93 $78.33 $98.07 $105.42 $57.64 $69.74 $73.26 $82.06 $102.74 $110.44 $60.26 $72.91 $76.59 $85.79 $107.41 $115.46 $62.88 $76.08 $79.92 $89.52 $112.08 $120.48 $65.50 $79.25 $83.25 $93.25 $116.75 $125.50 $68.12 $82.42 $86.58 $96.98 $121.42 $130.52 $70.74 $85.59 $89.91 $100.71 $126.09 $135.54 $73.36 $88.76 $93.24 $104.44 $130.76 $140.56 $75.98 $91.93 $96.57 $108.17 $135.43 $145.58 $78.60 $95.10 $99.90 $111.90 $140.10 $150.60 $81.22 $98.27 $103.23 $115.63 $144.77 $155.62 $83.84 $101.44 $106.56 $119.36 $149.44 $160.64 $86.46 $104.61 $109.89 $123.09 $154.11 $165.66 $89.08 $107.78 $113.22 $126.82 $158.78 $170.68 $91.70 $110.95 $116.55 $130.55 $163.45 $175.70 $94.32 $114.12 $119.88 $134.28 $168.12 $180.72 $96.94 $117.29 $123.21 $138.01 $172.79 $185.74 $99.56 $120.46 $126.54 $141.74 $177.46 $190.76 $102.18 $123.63 $129.87 $145.47 $182.13 $195.78 $104.80 $126.80 $133.20 $149.20 $186.80 $200.80 $107.42 $129.97 $136.53 $152.93 $191.47 $205.82 $110.04 $133.14 $139.86 $156.66 $196.14 $210.84 $112.66 $136.31 $143.19 $160.39 $200.81 $215.86 $115.28 $139.48 $146.52 $164.12 $205.48 $220.88 $117.90 $142.65 $149.85 $167.85 $210.15 $225.90 $120.52 $145.82 $153.18 $171.58 $214.82 $230.92 $123.14 $148.99 $156.51 $175.31 $219.49 $235.94 $125.76 $152.16 $159.84 $179.04 $224.16 $240.96 $128.38 $155.33 $163.17 $182.77 $228.83 $245.98 $131.00 $158.50 $166.50 $186.50 $233.50 $251.00 $133.62 $161.67 $169.83 $190.23 $238.17 $256.02
Ages 60+ $11.52 $17.28 $23.04 $28.80 $34.56 $40.32 $46.08 $51.84 $57.60 $63.36 $69.12 $74.88 $80.64 $86.40 $92.16 $97.92 $103.68 $109.44 $115.20 $120.96 $126.72 $132.48 $138.24 $144.00 $149.76 $155.52 $161.28 $167.04 $172.80 $178.56 $184.32 $190.08 $195.84 $201.60 $207.36 $213.12 $218.88 $224.64 $230.40 $236.16 $241.92 $247.68 $253.44 $259.20 $264.96 $270.72 $276.48 $282.24 $288.00 $293.76
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $115.44 $117.66 $119.88 $122.10 $124.32 $126.54 $128.76 $130.98 $133.20 $135.42 $137.64 $139.86 $142.08 $144.30 $146.52 $148.74 $150.96 $153.18 $155.40 $157.62 $159.84 $162.06 $164.28 $166.50 $168.72 $170.94 $173.16 $175.38 $177.60 $179.82 $182.04 $184.26 $186.48 $188.70 $190.92 $193.14 $195.36 $197.58 $199.80 $202.02 $204.24 $206.46 $208.68 $210.90 $213.12 $215.34 $217.56 $219.78 $222.00
14 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $136.24 $164.84 $173.16 $193.96 $242.84 $261.04 $138.86 $168.01 $176.49 $197.69 $247.51 $266.06 $141.48 $171.18 $179.82 $201.42 $252.18 $271.08 $144.10 $174.35 $183.15 $205.15 $256.85 $276.10 $146.72 $177.52 $186.48 $208.88 $261.52 $281.12 $149.34 $180.69 $189.81 $212.61 $266.19 $286.14 $151.96 $183.86 $193.14 $216.34 $270.86 $291.16 $154.58 $187.03 $196.47 $220.07 $275.53 $296.18 $157.20 $190.20 $199.80 $223.80 $280.20 $301.20 $159.82 $193.37 $203.13 $227.53 $284.87 $306.22 $162.44 $196.54 $206.46 $231.26 $289.54 $311.24 $165.06 $199.71 $209.79 $234.99 $294.21 $316.26 $167.68 $202.88 $213.12 $238.72 $298.88 $321.28 $170.30 $206.05 $216.45 $242.45 $303.55 $326.30 $172.92 $209.22 $219.78 $246.18 $308.22 $331.32 $175.54 $212.39 $223.11 $249.91 $312.89 $336.34 $178.16 $215.56 $226.44 $253.64 $317.56 $341.36 $180.78 $218.73 $229.77 $257.37 $322.23 $346.38 $183.40 $221.90 $233.10 $261.10 $326.90 $351.40 $186.02 $225.07 $236.43 $264.83 $331.57 $356.42 $188.64 $228.24 $239.76 $268.56 $336.24 $361.44 $191.26 $231.41 $243.09 $272.29 $340.91 $366.46 $193.88 $234.58 $246.42 $276.02 $345.58 $371.48 $196.50 $237.75 $249.75 $279.75 $350.25 $376.50 $199.12 $240.92 $253.08 $283.48 $354.92 $381.52 $201.74 $244.09 $256.41 $287.21 $359.59 $386.54 $204.36 $247.26 $259.74 $290.94 $364.26 $391.56 $206.98 $250.43 $263.07 $294.67 $368.93 $396.58 $209.60 $253.60 $266.40 $298.40 $373.60 $401.60 $212.22 $256.77 $269.73 $302.13 $378.27 $406.62 $214.84 $259.94 $273.06 $305.86 $382.94 $411.64 $217.46 $263.11 $276.39 $309.59 $387.61 $416.66 $220.08 $266.28 $279.72 $313.32 $392.28 $421.68 $222.70 $269.45 $283.05 $317.05 $396.95 $426.70 $225.32 $272.62 $286.38 $320.78 $401.62 $431.72 $227.94 $275.79 $289.71 $324.51 $406.29 $436.74 $230.56 $278.96 $293.04 $328.24 $410.96 $441.76 $233.18 $282.13 $296.37 $331.97 $415.63 $446.78 $235.80 $285.30 $299.70 $335.70 $420.30 $451.80 $238.42 $288.47 $303.03 $339.43 $424.97 $456.82 $241.04 $291.64 $306.36 $343.16 $429.64 $461.84 $243.66 $294.81 $309.69 $346.89 $434.31 $466.86 $246.28 $297.98 $313.02 $350.62 $438.98 $471.88 $248.90 $301.15 $316.35 $354.35 $443.65 $476.90 $251.52 $304.32 $319.68 $358.08 $448.32 $481.92 $254.14 $307.49 $323.01 $361.81 $452.99 $486.94 $256.76 $310.66 $326.34 $365.54 $457.66 $491.96 $259.38 $313.83 $329.67 $369.27 $462.33 $496.98 $262.00 $317.00 $333.00 $373.00 $467.00 $502.00
Ages 60+ $299.52 $305.28 $311.04 $316.80 $322.56 $328.32 $334.08 $339.84 $345.60 $351.36 $357.12 $362.88 $368.64 $374.40 $380.16 $385.92 $391.68 $397.44 $403.20 $408.96 $414.72 $420.48 $426.24 $432.00 $437.76 $443.52 $449.28 $455.04 $460.80 $466.56 $472.32 $478.08 $483.84 $489.60 $495.36 $501.12 $506.88 $512.64 $518.40 $524.16 $529.92 $535.68 $541.44 $547.20 $552.96 $558.72 $564.48 $570.24 57 $576.00
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 58 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $3.68 $5.52 $7.36 $9.20 $11.04 $12.88 $14.72 $16.56 $18.40 $20.24 $22.08 $23.92 $25.76 $27.60 $29.44 $31.28 $33.12 $34.96 $36.80 $38.64 $40.48 $42.32 $44.16 $46.00 $47.84 $49.68 $51.52 $53.36 $55.20 $57.04 $58.88 $60.72 $62.56 $64.40 $66.24 $68.08 $69.92 $71.76 $73.60 $75.44 $77.28 $79.12 $80.96 $82.80 $84.64 $86.48 $88.32 $90.16 $92.00 $93.84
30 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $4.34 $5.26 $5.56 $6.20 $7.78 $8.34 $6.51 $7.89 $8.34 $9.30 $11.67 $12.51 $8.68 $10.52 $11.12 $12.40 $15.56 $16.68 $10.85 $13.15 $13.90 $15.50 $19.45 $20.85 $13.02 $15.78 $16.68 $18.60 $23.34 $25.02 $15.19 $18.41 $19.46 $21.70 $27.23 $29.19 $17.36 $21.04 $22.24 $24.80 $31.12 $33.36 $19.53 $23.67 $25.02 $27.90 $35.01 $37.53 $21.70 $26.30 $27.80 $31.00 $38.90 $41.70 $23.87 $28.93 $30.58 $34.10 $42.79 $45.87 $26.04 $31.56 $33.36 $37.20 $46.68 $50.04 $28.21 $34.19 $36.14 $40.30 $50.57 $54.21 $30.38 $36.82 $38.92 $43.40 $54.46 $58.38 $32.55 $39.45 $41.70 $46.50 $58.35 $62.55 $34.72 $42.08 $44.48 $49.60 $62.24 $66.72 $36.89 $44.71 $47.26 $52.70 $66.13 $70.89 $39.06 $47.34 $50.04 $55.80 $70.02 $75.06 $41.23 $49.97 $52.82 $58.90 $73.91 $79.23 $43.40 $52.60 $55.60 $62.00 $77.80 $83.40 $45.57 $55.23 $58.38 $65.10 $81.69 $87.57 $47.74 $57.86 $61.16 $68.20 $85.58 $91.74 $49.91 $60.49 $63.94 $71.30 $89.47 $95.91 $52.08 $63.12 $66.72 $74.40 $93.36 $100.08 $54.25 $65.75 $69.50 $77.50 $97.25 $104.25 $56.42 $68.38 $72.28 $80.60 $101.14 $108.42 $58.59 $71.01 $75.06 $83.70 $105.03 $112.59 $60.76 $73.64 $77.84 $86.80 $108.92 $116.76 $62.93 $76.27 $80.62 $89.90 $112.81 $120.93 $65.10 $78.90 $83.40 $93.00 $116.70 $125.10 $67.27 $81.53 $86.18 $96.10 $120.59 $129.27 $69.44 $84.16 $88.96 $99.20 $124.48 $133.44 $71.61 $86.79 $91.74 $102.30 $128.37 $137.61 $73.78 $89.42 $94.52 $105.40 $132.26 $141.78 $75.95 $92.05 $97.30 $108.50 $136.15 $145.95 $78.12 $94.68 $100.08 $111.60 $140.04 $150.12 $80.29 $97.31 $102.86 $114.70 $143.93 $154.29 $82.46 $99.94 $105.64 $117.80 $147.82 $158.46 $84.63 $102.57 $108.42 $120.90 $151.71 $162.63 $86.80 $105.20 $111.20 $124.00 $155.60 $166.80 $88.97 $107.83 $113.98 $127.10 $159.49 $170.97 $91.14 $110.46 $116.76 $130.20 $163.38 $175.14 $93.31 $113.09 $119.54 $133.30 $167.27 $179.31 $95.48 $115.72 $122.32 $136.40 $171.16 $183.48 $97.65 $118.35 $125.10 $139.50 $175.05 $187.65 $99.82 $120.98 $127.88 $142.60 $178.94 $191.82 $101.99 $123.61 $130.66 $145.70 $182.83 $195.99 $104.16 $126.24 $133.44 $148.80 $186.72 $200.16 $106.33 $128.87 $136.22 $151.90 $190.61 $204.33 $108.50 $131.50 $139.00 $155.00 $194.50 $208.50 $110.67 $134.13 $141.78 $158.10 $198.39 $212.67
Ages 60+ $9.60 $14.40 $19.20 $24.00 $28.80 $33.60 $38.40 $43.20 $48.00 $52.80 $57.60 $62.40 $67.20 $72.00 $76.80 $81.60 $86.40 $91.20 $96.00 $100.80 $105.60 $110.40 $115.20 $120.00 $124.80 $129.60 $134.40 $139.20 $144.00 $148.80 $153.60 $158.40 $163.20 $168.00 $172.80 $177.60 $182.40 $187.20 $192.00 $196.80 $201.60 $206.40 $211.20 $216.00 $220.80 $225.60 $230.40 $235.20 $240.00 $244.80
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $95.68 $97.52 $99.36 $101.20 $103.04 $104.88 $106.72 $108.56 $110.40 $112.24 $114.08 $115.92 $117.76 $119.60 $121.44 $123.28 $125.12 $126.96 $128.80 $130.64 $132.48 $134.32 $136.16 $138.00 $139.84 $141.68 $143.52 $145.36 $147.20 $149.04 $150.88 $152.72 $154.56 $156.40 $158.24 $160.08 $161.92 $163.76 $165.60 $167.44 $169.28 $171.12 $172.96 $174.80 $176.64 $178.48 $180.32 $182.16 $184.00
30 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $112.84 $136.76 $144.56 $161.20 $202.28 $216.84 $115.01 $139.39 $147.34 $164.30 $206.17 $221.01 $117.18 $142.02 $150.12 $167.40 $210.06 $225.18 $119.35 $144.65 $152.90 $170.50 $213.95 $229.35 $121.52 $147.28 $155.68 $173.60 $217.84 $233.52 $123.69 $149.91 $158.46 $176.70 $221.73 $237.69 $125.86 $152.54 $161.24 $179.80 $225.62 $241.86 $128.03 $155.17 $164.02 $182.90 $229.51 $246.03 $130.20 $157.80 $166.80 $186.00 $233.40 $250.20 $132.37 $160.43 $169.58 $189.10 $237.29 $254.37 $134.54 $163.06 $172.36 $192.20 $241.18 $258.54 $136.71 $165.69 $175.14 $195.30 $245.07 $262.71 $138.88 $168.32 $177.92 $198.40 $248.96 $266.88 $141.05 $170.95 $180.70 $201.50 $252.85 $271.05 $143.22 $173.58 $183.48 $204.60 $256.74 $275.22 $145.39 $176.21 $186.26 $207.70 $260.63 $279.39 $147.56 $178.84 $189.04 $210.80 $264.52 $283.56 $149.73 $181.47 $191.82 $213.90 $268.41 $287.73 $151.90 $184.10 $194.60 $217.00 $272.30 $291.90 $154.07 $186.73 $197.38 $220.10 $276.19 $296.07 $156.24 $189.36 $200.16 $223.20 $280.08 $300.24 $158.41 $191.99 $202.94 $226.30 $283.97 $304.41 $160.58 $194.62 $205.72 $229.40 $287.86 $308.58 $162.75 $197.25 $208.50 $232.50 $291.75 $312.75 $164.92 $199.88 $211.28 $235.60 $295.64 $316.92 $167.09 $202.51 $214.06 $238.70 $299.53 $321.09 $169.26 $205.14 $216.84 $241.80 $303.42 $325.26 $171.43 $207.77 $219.62 $244.90 $307.31 $329.43 $173.60 $210.40 $222.40 $248.00 $311.20 $333.60 $175.77 $213.03 $225.18 $251.10 $315.09 $337.77 $177.94 $215.66 $227.96 $254.20 $318.98 $341.94 $180.11 $218.29 $230.74 $257.30 $322.87 $346.11 $182.28 $220.92 $233.52 $260.40 $326.76 $350.28 $184.45 $223.55 $236.30 $263.50 $330.65 $354.45 $186.62 $226.18 $239.08 $266.60 $334.54 $358.62 $188.79 $228.81 $241.86 $269.70 $338.43 $362.79 $190.96 $231.44 $244.64 $272.80 $342.32 $366.96 $193.13 $234.07 $247.42 $275.90 $346.21 $371.13 $195.30 $236.70 $250.20 $279.00 $350.10 $375.30 $197.47 $239.33 $252.98 $282.10 $353.99 $379.47 $199.64 $241.96 $255.76 $285.20 $357.88 $383.64 $201.81 $244.59 $258.54 $288.30 $361.77 $387.81 $203.98 $247.22 $261.32 $291.40 $365.66 $391.98 $206.15 $249.85 $264.10 $294.50 $369.55 $396.15 $208.32 $252.48 $266.88 $297.60 $373.44 $400.32 $210.49 $255.11 $269.66 $300.70 $377.33 $404.49 $212.66 $257.74 $272.44 $303.80 $381.22 $408.66 $214.83 $260.37 $275.22 $306.90 $385.11 $412.83 $217.00 $263.00 $278.00 $310.00 $389.00 $417.00
Ages 60+ $249.60 $254.40 $259.20 $264.00 $268.80 $273.60 $278.40 $283.20 $288.00 $292.80 $297.60 $302.40 $307.20 $312.00 $316.80 $321.60 $326.40 $331.20 $336.00 $340.80 $345.60 $350.40 $355.20 $360.00 $364.80 $369.60 $374.40 $379.20 $384.00 $388.80 $393.60 $398.40 $403.20 $408.00 $412.80 $417.60 $422.40 $427.20 $432.00 $436.80 $441.60 $446.40 $451.20 $456.00 $460.80 $465.60 $470.40 $475.20 59 $480.00
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 60 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $2.92 $4.38 $5.84 $7.30 $8.76 $10.22 $11.68 $13.14 $14.60 $16.06 $17.52 $18.98 $20.44 $21.90 $23.36 $24.82 $26.28 $27.74 $29.20 $30.66 $32.12 $33.58 $35.04 $36.50 $37.96 $39.42 $40.88 $42.34 $43.80 $45.26 $46.72 $48.18 $49.64 $51.10 $52.56 $54.02 $55.48 $56.94 $58.40 $59.86 $61.32 $62.78 $64.24 $65.70 $67.16 $68.62 $70.08 $71.54 $73.00 $74.46
45 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $3.42 $4.18 $4.44 $4.94 $6.20 $6.62 $5.13 $6.27 $6.66 $7.41 $9.30 $9.93 $6.84 $8.36 $8.88 $9.88 $12.40 $13.24 $8.55 $10.45 $11.10 $12.35 $15.50 $16.55 $10.26 $12.54 $13.32 $14.82 $18.60 $19.86 $11.97 $14.63 $15.54 $17.29 $21.70 $23.17 $13.68 $16.72 $17.76 $19.76 $24.80 $26.48 $15.39 $18.81 $19.98 $22.23 $27.90 $29.79 $17.10 $20.90 $22.20 $24.70 $31.00 $33.10 $18.81 $22.99 $24.42 $27.17 $34.10 $36.41 $20.52 $25.08 $26.64 $29.64 $37.20 $39.72 $22.23 $27.17 $28.86 $32.11 $40.30 $43.03 $23.94 $29.26 $31.08 $34.58 $43.40 $46.34 $25.65 $31.35 $33.30 $37.05 $46.50 $49.65 $27.36 $33.44 $35.52 $39.52 $49.60 $52.96 $29.07 $35.53 $37.74 $41.99 $52.70 $56.27 $30.78 $37.62 $39.96 $44.46 $55.80 $59.58 $32.49 $39.71 $42.18 $46.93 $58.90 $62.89 $34.20 $41.80 $44.40 $49.40 $62.00 $66.20 $35.91 $43.89 $46.62 $51.87 $65.10 $69.51 $37.62 $45.98 $48.84 $54.34 $68.20 $72.82 $39.33 $48.07 $51.06 $56.81 $71.30 $76.13 $41.04 $50.16 $53.28 $59.28 $74.40 $79.44 $42.75 $52.25 $55.50 $61.75 $77.50 $82.75 $44.46 $54.34 $57.72 $64.22 $80.60 $86.06 $46.17 $56.43 $59.94 $66.69 $83.70 $89.37 $47.88 $58.52 $62.16 $69.16 $86.80 $92.68 $49.59 $60.61 $64.38 $71.63 $89.90 $95.99 $51.30 $62.70 $66.60 $74.10 $93.00 $99.30 $53.01 $64.79 $68.82 $76.57 $96.10 $102.61 $54.72 $66.88 $71.04 $79.04 $99.20 $105.92 $56.43 $68.97 $73.26 $81.51 $102.30 $109.23 $58.14 $71.06 $75.48 $83.98 $105.40 $112.54 $59.85 $73.15 $77.70 $86.45 $108.50 $115.85 $61.56 $75.24 $79.92 $88.92 $111.60 $119.16 $63.27 $77.33 $82.14 $91.39 $114.70 $122.47 $64.98 $79.42 $84.36 $93.86 $117.80 $125.78 $66.69 $81.51 $86.58 $96.33 $120.90 $129.09 $68.40 $83.60 $88.80 $98.80 $124.00 $132.40 $70.11 $85.69 $91.02 $101.27 $127.10 $135.71 $71.82 $87.78 $93.24 $103.74 $130.20 $139.02 $73.53 $89.87 $95.46 $106.21 $133.30 $142.33 $75.24 $91.96 $97.68 $108.68 $136.40 $145.64 $76.95 $94.05 $99.90 $111.15 $139.50 $148.95 $78.66 $96.14 $102.12 $113.62 $142.60 $152.26 $80.37 $98.23 $104.34 $116.09 $145.70 $155.57 $82.08 $100.32 $106.56 $118.56 $148.80 $158.88 $83.79 $102.41 $108.78 $121.03 $151.90 $162.19 $85.50 $104.50 $111.00 $123.50 $155.00 $165.50 $87.21 $106.59 $113.22 $125.97 $158.10 $168.81
Ages 60+ $7.66 $11.49 $15.32 $19.15 $22.98 $26.81 $30.64 $34.47 $38.30 $42.13 $45.96 $49.79 $53.62 $57.45 $61.28 $65.11 $68.94 $72.77 $76.60 $80.43 $84.26 $88.09 $91.92 $95.75 $99.58 $103.41 $107.24 $111.07 $114.90 $118.73 $122.56 $126.39 $130.22 $134.05 $137.88 $141.71 $145.54 $149.37 $153.20 $157.03 $160.86 $164.69 $168.52 $172.35 $176.18 $180.01 $183.84 $187.67 $191.50 $195.33
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $75.92 $77.38 $78.84 $80.30 $81.76 $83.22 $84.68 $86.14 $87.60 $89.06 $90.52 $91.98 $93.44 $94.90 $96.36 $97.82 $99.28 $100.74 $102.20 $103.66 $105.12 $106.58 $108.04 $109.50 $110.96 $112.42 $113.88 $115.34 $116.80 $118.26 $119.72 $121.18 $122.64 $124.10 $125.56 $127.02 $128.48 $129.94 $131.40 $132.86 $134.32 $135.78 $137.24 $138.70 $140.16 $141.62 $143.08 $144.54 $146.00
45 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $88.92 $108.68 $115.44 $128.44 $161.20 $172.12 $90.63 $110.77 $117.66 $130.91 $164.30 $175.43 $92.34 $112.86 $119.88 $133.38 $167.40 $178.74 $94.05 $114.95 $122.10 $135.85 $170.50 $182.05 $95.76 $117.04 $124.32 $138.32 $173.60 $185.36 $97.47 $119.13 $126.54 $140.79 $176.70 $188.67 $99.18 $121.22 $128.76 $143.26 $179.80 $191.98 $100.89 $123.31 $130.98 $145.73 $182.90 $195.29 $102.60 $125.40 $133.20 $148.20 $186.00 $198.60 $104.31 $127.49 $135.42 $150.67 $189.10 $201.91 $106.02 $129.58 $137.64 $153.14 $192.20 $205.22 $107.73 $131.67 $139.86 $155.61 $195.30 $208.53 $109.44 $133.76 $142.08 $158.08 $198.40 $211.84 $111.15 $135.85 $144.30 $160.55 $201.50 $215.15 $112.86 $137.94 $146.52 $163.02 $204.60 $218.46 $114.57 $140.03 $148.74 $165.49 $207.70 $221.77 $116.28 $142.12 $150.96 $167.96 $210.80 $225.08 $117.99 $144.21 $153.18 $170.43 $213.90 $228.39 $119.70 $146.30 $155.40 $172.90 $217.00 $231.70 $121.41 $148.39 $157.62 $175.37 $220.10 $235.01 $123.12 $150.48 $159.84 $177.84 $223.20 $238.32 $124.83 $152.57 $162.06 $180.31 $226.30 $241.63 $126.54 $154.66 $164.28 $182.78 $229.40 $244.94 $128.25 $156.75 $166.50 $185.25 $232.50 $248.25 $129.96 $158.84 $168.72 $187.72 $235.60 $251.56 $131.67 $160.93 $170.94 $190.19 $238.70 $254.87 $133.38 $163.02 $173.16 $192.66 $241.80 $258.18 $135.09 $165.11 $175.38 $195.13 $244.90 $261.49 $136.80 $167.20 $177.60 $197.60 $248.00 $264.80 $138.51 $169.29 $179.82 $200.07 $251.10 $268.11 $140.22 $171.38 $182.04 $202.54 $254.20 $271.42 $141.93 $173.47 $184.26 $205.01 $257.30 $274.73 $143.64 $175.56 $186.48 $207.48 $260.40 $278.04 $145.35 $177.65 $188.70 $209.95 $263.50 $281.35 $147.06 $179.74 $190.92 $212.42 $266.60 $284.66 $148.77 $181.83 $193.14 $214.89 $269.70 $287.97 $150.48 $183.92 $195.36 $217.36 $272.80 $291.28 $152.19 $186.01 $197.58 $219.83 $275.90 $294.59 $153.90 $188.10 $199.80 $222.30 $279.00 $297.90 $155.61 $190.19 $202.02 $224.77 $282.10 $301.21 $157.32 $192.28 $204.24 $227.24 $285.20 $304.52 $159.03 $194.37 $206.46 $229.71 $288.30 $307.83 $160.74 $196.46 $208.68 $232.18 $291.40 $311.14 $162.45 $198.55 $210.90 $234.65 $294.50 $314.45 $164.16 $200.64 $213.12 $237.12 $297.60 $317.76 $165.87 $202.73 $215.34 $239.59 $300.70 $321.07 $167.58 $204.82 $217.56 $242.06 $303.80 $324.38 $169.29 $206.91 $219.78 $244.53 $306.90 $327.69 $171.00 $209.00 $222.00 $247.00 $310.00 $331.00
Ages 60+ $199.16 $202.99 $206.82 $210.65 $214.48 $218.31 $222.14 $225.97 $229.80 $233.63 $237.46 $241.29 $245.12 $248.95 $252.78 $256.61 $260.44 $264.27 $268.10 $271.93 $275.76 $279.59 $283.42 $287.25 $291.08 $294.91 $298.74 $302.57 $306.40 $310.23 $314.06 $317.89 $321.72 $325.55 $329.38 $333.21 $337.04 $340.87 $344.70 $348.53 $352.36 $356.19 $360.02 $363.85 $367.68 $371.51 $375.34 $379.17 61 $383.00
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 62 $91,800
Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650
Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100
Under Age 30 $2.38 $3.57 $4.76 $5.95 $7.14 $8.33 $9.52 $10.71 $11.90 $13.09 $14.28 $15.47 $16.66 $17.85 $19.04 $20.23 $21.42 $22.61 $23.80 $24.99 $26.18 $27.37 $28.56 $29.75 $30.94 $32.13 $33.32 $34.51 $35.70 $36.89 $38.08 $39.27 $40.46 $41.65 $42.84 $44.03 $45.22 $46.41 $47.60 $48.79 $49.98 $51.17 $52.36 $53.55 $54.74 $55.93 $57.12 $58.31 $59.50 $60.69
90 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $2.76 $3.38 $3.56 $3.98 $4.98 $5.44 $4.14 $5.07 $5.34 $5.97 $7.47 $8.16 $5.52 $6.76 $7.12 $7.96 $9.96 $10.88 $6.90 $8.45 $8.90 $9.95 $12.45 $13.60 $8.28 $10.14 $10.68 $11.94 $14.94 $16.32 $9.66 $11.83 $12.46 $13.93 $17.43 $19.04 $11.04 $13.52 $14.24 $15.92 $19.92 $21.76 $12.42 $15.21 $16.02 $17.91 $22.41 $24.48 $13.80 $16.90 $17.80 $19.90 $24.90 $27.20 $15.18 $18.59 $19.58 $21.89 $27.39 $29.92 $16.56 $20.28 $21.36 $23.88 $29.88 $32.64 $17.94 $21.97 $23.14 $25.87 $32.37 $35.36 $19.32 $23.66 $24.92 $27.86 $34.86 $38.08 $20.70 $25.35 $26.70 $29.85 $37.35 $40.80 $22.08 $27.04 $28.48 $31.84 $39.84 $43.52 $23.46 $28.73 $30.26 $33.83 $42.33 $46.24 $24.84 $30.42 $32.04 $35.82 $44.82 $48.96 $26.22 $32.11 $33.82 $37.81 $47.31 $51.68 $27.60 $33.80 $35.60 $39.80 $49.80 $54.40 $28.98 $35.49 $37.38 $41.79 $52.29 $57.12 $30.36 $37.18 $39.16 $43.78 $54.78 $59.84 $31.74 $38.87 $40.94 $45.77 $57.27 $62.56 $33.12 $40.56 $42.72 $47.76 $59.76 $65.28 $34.50 $42.25 $44.50 $49.75 $62.25 $68.00 $35.88 $43.94 $46.28 $51.74 $64.74 $70.72 $37.26 $45.63 $48.06 $53.73 $67.23 $73.44 $38.64 $47.32 $49.84 $55.72 $69.72 $76.16 $40.02 $49.01 $51.62 $57.71 $72.21 $78.88 $41.40 $50.70 $53.40 $59.70 $74.70 $81.60 $42.78 $52.39 $55.18 $61.69 $77.19 $84.32 $44.16 $54.08 $56.96 $63.68 $79.68 $87.04 $45.54 $55.77 $58.74 $65.67 $82.17 $89.76 $46.92 $57.46 $60.52 $67.66 $84.66 $92.48 $48.30 $59.15 $62.30 $69.65 $87.15 $95.20 $49.68 $60.84 $64.08 $71.64 $89.64 $97.92 $51.06 $62.53 $65.86 $73.63 $92.13 $100.64 $52.44 $64.22 $67.64 $75.62 $94.62 $103.36 $53.82 $65.91 $69.42 $77.61 $97.11 $106.08 $55.20 $67.60 $71.20 $79.60 $99.60 $108.80 $56.58 $69.29 $72.98 $81.59 $102.09 $111.52 $57.96 $70.98 $74.76 $83.58 $104.58 $114.24 $59.34 $72.67 $76.54 $85.57 $107.07 $116.96 $60.72 $74.36 $78.32 $87.56 $109.56 $119.68 $62.10 $76.05 $80.10 $89.55 $112.05 $122.40 $63.48 $77.74 $81.88 $91.54 $114.54 $125.12 $64.86 $79.43 $83.66 $93.53 $117.03 $127.84 $66.24 $81.12 $85.44 $95.52 $119.52 $130.56 $67.62 $82.81 $87.22 $97.51 $122.01 $133.28 $69.00 $84.50 $89.00 $99.50 $124.50 $136.00 $70.38 $86.19 $90.78 $101.49 $126.99 $138.72
Ages 60+ $6.20 $9.30 $12.40 $15.50 $18.60 $21.70 $24.80 $27.90 $31.00 $34.10 $37.20 $40.30 $43.40 $46.50 $49.60 $52.70 $55.80 $58.90 $62.00 $65.10 $68.20 $71.30 $74.40 $77.50 $80.60 $83.70 $86.80 $89.90 $93.00 $96.10 $99.20 $102.30 $105.40 $108.50 $111.60 $114.70 $117.80 $120.90 $124.00 $127.10 $130.20 $133.30 $136.40 $139.50 $142.60 $145.70 $148.80 $151.90 $155.00 $158.10
Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000
Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000
Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000
Under Age 30 $61.88 $63.07 $64.26 $65.45 $66.64 $67.83 $69.02 $70.21 $71.40 $72.59 $73.78 $74.97 $76.16 $77.35 $78.54 $79.73 $80.92 $82.11 $83.30 $84.49 $85.68 $86.87 $88.06 $89.25 $90.44 $91.63 $92.82 $94.01 $95.20 $96.39 $97.58 $98.77 $99.96 $101.15 $102.34 $103.53 $104.72 $105.91 $107.10 $108.29 $109.48 $110.67 $111.86 $113.05 $114.24 $115.43 $116.62 $117.81 $119.00
90 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $71.76 $87.88 $92.56 $103.48 $129.48 $141.44 $73.14 $89.57 $94.34 $105.47 $131.97 $144.16 $74.52 $91.26 $96.12 $107.46 $134.46 $146.88 $75.90 $92.95 $97.90 $109.45 $136.95 $149.60 $77.28 $94.64 $99.68 $111.44 $139.44 $152.32 $78.66 $96.33 $101.46 $113.43 $141.93 $155.04 $80.04 $98.02 $103.24 $115.42 $144.42 $157.76 $81.42 $99.71 $105.02 $117.41 $146.91 $160.48 $82.80 $101.40 $106.80 $119.40 $149.40 $163.20 $84.18 $103.09 $108.58 $121.39 $151.89 $165.92 $85.56 $104.78 $110.36 $123.38 $154.38 $168.64 $86.94 $106.47 $112.14 $125.37 $156.87 $171.36 $88.32 $108.16 $113.92 $127.36 $159.36 $174.08 $89.70 $109.85 $115.70 $129.35 $161.85 $176.80 $91.08 $111.54 $117.48 $131.34 $164.34 $179.52 $92.46 $113.23 $119.26 $133.33 $166.83 $182.24 $93.84 $114.92 $121.04 $135.32 $169.32 $184.96 $95.22 $116.61 $122.82 $137.31 $171.81 $187.68 $96.60 $118.30 $124.60 $139.30 $174.30 $190.40 $97.98 $119.99 $126.38 $141.29 $176.79 $193.12 $99.36 $121.68 $128.16 $143.28 $179.28 $195.84 $100.74 $123.37 $129.94 $145.27 $181.77 $198.56 $102.12 $125.06 $131.72 $147.26 $184.26 $201.28 $103.50 $126.75 $133.50 $149.25 $186.75 $204.00 $104.88 $128.44 $135.28 $151.24 $189.24 $206.72 $106.26 $130.13 $137.06 $153.23 $191.73 $209.44 $107.64 $131.82 $138.84 $155.22 $194.22 $212.16 $109.02 $133.51 $140.62 $157.21 $196.71 $214.88 $110.40 $135.20 $142.40 $159.20 $199.20 $217.60 $111.78 $136.89 $144.18 $161.19 $201.69 $220.32 $113.16 $138.58 $145.96 $163.18 $204.18 $223.04 $114.54 $140.27 $147.74 $165.17 $206.67 $225.76 $115.92 $141.96 $149.52 $167.16 $209.16 $228.48 $117.30 $143.65 $151.30 $169.15 $211.65 $231.20 $118.68 $145.34 $153.08 $171.14 $214.14 $233.92 $120.06 $147.03 $154.86 $173.13 $216.63 $236.64 $121.44 $148.72 $156.64 $175.12 $219.12 $239.36 $122.82 $150.41 $158.42 $177.11 $221.61 $242.08 $124.20 $152.10 $160.20 $179.10 $224.10 $244.80 $125.58 $153.79 $161.98 $181.09 $226.59 $247.52 $126.96 $155.48 $163.76 $183.08 $229.08 $250.24 $128.34 $157.17 $165.54 $185.07 $231.57 $252.96 $129.72 $158.86 $167.32 $187.06 $234.06 $255.68 $131.10 $160.55 $169.10 $189.05 $236.55 $258.40 $132.48 $162.24 $170.88 $191.04 $239.04 $261.12 $133.86 $163.93 $172.66 $193.03 $241.53 $263.84 $135.24 $165.62 $174.44 $195.02 $244.02 $266.56 $136.62 $167.31 $176.22 $197.01 $246.51 $269.28 $138.00 $169.00 $178.00 $199.00 $249.00 $272.00
Ages 60+ $161.20 $164.30 $167.40 $170.50 $173.60 $176.70 $179.80 $182.90 $186.00 $189.10 $192.20 $195.30 $198.40 $201.50 $204.60 $207.70 $210.80 $213.90 $217.00 $220.10 $223.20 $226.30 $229.40 $232.50 $235.60 $238.70 $241.80 $244.90 $248.00 $251.10 $254.20 $257.30 $260.40 $263.50 $266.60 $269.70 $272.80 $275.90 $279.00 $282.10 $285.20 $288.30 $291.40 $294.50 $297.60 $300.70 $303.80 $306.90 63 $310.00
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 64 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
GC14 Limited Benefit Group Cancer Indemnity Insurance Fort Worth Independent School District THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Summary of Benefits
Plan 1
Plan 2
Cancer Treatment Policy Benefits
Level 3
Level 4
Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period Hormone Therapy - Maximum of 12 treatments per calendar year
$15,000
$20,000
$50 per treatment
$50 per treatment
Experimental Treatment Cancer Screening Rider Benefits
paid in same manner and under the same maximums as any other benefit Level 1 Level 1
Diagnostic Testing - 1 test per calendar year
$50 per test
$50 per test
Follow-Up Diagnostic Testing - 1 test per calendar year
$100 per test
$100 per test
Medical Imaging - 1 test per calendar year
$500 per test
$500 per test
Internal Cancer First Occurrence Rider Benefits
Level 2
Level 4
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$5,000
$10,000
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$7,500
$15,000
Heart Attack/Stroke First Occurrence Rider Benefits
Level 2
Level 4
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$5,000
$10,000
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$7,500
$15,000
Total Monthly Premiums by Plan** Issue Ages 18 +
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Plan 1
Plan 2
Plan 1
Plan 2
Plan 1
Plan 2
Plan 1
Plan 2
$15.66
$25.00
$33.38
$53.84
$18.30
$29.10
$36.02
$57.98
**Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.
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APSB-22339(TX)-0616 MGM/FBS Fort Worth ISD
GC14 Limited Benefit Group Cancer Indemnity Insurance Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.
Cancer Treatment Benefits Eligibility
You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.
Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.
Only Loss for Cancer
The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, the time limit on certain defenses and preexisting condition exclusion for such increase will be based on the effective date of such increase.
Waiting Period
The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium. If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.
Termination of Certificate
Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.
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APSB-22339(TX)-0616 MGM/FBS Fort Worth ISD
Termination of Coverage
Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.
Cancer Screening Benefits Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.
Termination of Cancer Screening Benefit Rider The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.
Internal Cancer First Occurrence Benefits Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
Limitations and Exclusions
We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.
Waiting Period
This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.
GC14 Limited Benefit Group Cancer Indemnity Insurance Heart Attack/Stroke First Occurrence Benefits Optionally Renewable Pays a lump sum benefit amount when a covered person receives a first diagnosis of heart attack or stroke and the date of diagnosis occurs after the waiting period. Only one benefit per covered person per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.
Limitations and Exclusions
When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.
We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a Pre-Existing Condition.
Waiting Period
This rider contains a 30-day waiting period during which no benefits will be paid. If any heart attack or stroke is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date.
Portability (Voluntary Plans Only)
The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of a covered person’s death or the date the lump sum benefit amount for heart attack or stroke has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent, as defined in the policy.
2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | Fort Worth ISD 67
APSB-22339(TX)-0616 MGM/FBS Fort Worth ISD
METLIFE
Life and AD&D
YOUR BENEFITS PACKAGE
About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.
Motor vehicle crashes are the
#1
cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 68 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Life and AD&D Fort Worth Independent School District Ac ve Employee Life Plan Benefits Life insurance is a cost‐effec ve way to protect your family and your finances. It helps ensure your short‐ and long‐term financial obliga ons could be met if something unforeseen happens to you.
Use the table below to calculate your premium based on the amount of life insurance you will need. Example: $100,000 Supplemental Life Coverage 1. Enter the rate from the table (example age 36)
$0.076
$ ________
Explore the coverage that makes it easy to give yourself and your loved ones more security today…and in the future.
2. Enter the amount of insurance in thousands of dollars (Example: for $100,000 of coverage enter $100)
$100
$ ________
Basic Term Life Insurance
2. Monthly premium (1) x (2)
$7.60
$ ________
Your employer provides you with Basic Term Life insurance coverage in the amount of $15,000.
Supplemental Term Life Insurance Coverage Op ons An amount elected by you that is a mul ple of $10,000 to a maximum of $500,000
For You
For Your Spouse
An amount elected by you that is a mul ple of $10,000 to a maximum of $100,000, up to 100% of your coverage amount.
For Your Dependent Children*
$5,000, $10,000 or $15,000
*Child(ren)’s Eligibility: Dependent children ages from birth to age 26 are eligible for coverage, regardless of student status.
Monthly Costs* for Supplemental Term Life and Dependent Term Life with Accidental Death and Dismemberment Insurance You have the op on to purchase Supplemental Term Life Insurance. Listed below are your monthly rates (based on your age as of your last birthday) as well as those for your spouse (based on your spouse’s age as of his/her last birthday). Rates to cover your child(ren) are also shown. Age 0‐39 40‐44 45‐49 50‐54 55‐59 60‐64 65+
Monthly Cost Per $1,000 of Employee Coverage $0.076 $0.235 $0.235 $0.311 $0.625 $0.879 $0.956
Cost for your Child(ren)†
Monthly Cost Per $1,000 of Spouse Coverage $0.076 $0.235 $0.235 $0.311 $0.625 $0.879 $0.956 $ 5,000 ‐ $1.335 $10,000 ‐ $2.670 $15,000 ‐ $4.005
† Covers all eligible children *Note: rates are subject to the policy’s right to change premium rates, and the employer’s right to change employee contribu ons.
Repeat the three easy steps above to determine the cost for each coverage selected.
Once Enrolled, You have Access to MetLife AdvantagesSM – Services to Help Navigate What Life May Bring Grief Counseling (all states except NY)1 To help you, your dependents, and your beneficiaries cope with loss You, your dependents, and your beneficiaries have access to grief counseling1 sessions and funeral related concierge services to help cope with a loss — at no extra cost. Grief counseling services provide confiden al and professional support during a difficult me to help address personal and funeral planning needs. At your me of need, you and your dependents have 24/7 access to a work/life counselor. You simply call a dedicated 24/7 toll‐free number to speak with a licensed professional experienced in helping individuals who have suffered a loss. Sessions can either take place in‐person or by phone. You can have up to five face‐to‐face grief counseling sessions per event to discuss any situa on you perceive as a major loss, including but not limited to death, bankruptcy, divorce, terminal illness, or losing a pet.1 In addi on, you have access to funeral assistance for loca ng funeral homes and cemetery op ons, obtaining funeral cost es mates and comparisons, and more. You can access these services by calling 1‐888‐319‐7819 or log on to www.metlifegc.lifeworks.com (Username: metlifeassist; Password: support). Download this helpful Funeral Planning Guide at h ps:// www.metlife.com/funeralplanning/funeral‐guide/.
Beneficiary Claim Assistance3 For support when beneficiaries need it most This program is designed to help beneficiaries sort through the details and serious ques ons about claims and financial needs during a difficult me. MetLife has arranged for Massachuse s Mutual Life Insurance Company (Mass Mutual) financial professionals to be available for assistance in‐person or by telephone to help with filing life insurance claims, government benefits and help with financial ques ons.
69
Life and AD&D MetLife Estate Resolu on ServicesSM provides probate services in person or over the phone to the representa ve (executor or For immediate access to death proceeds administrator) of the deceased employee's estate and the estate The Total Control Account® (TCA) se lement op on provides your loved ones with a safe and convenient way to manage the of the employee's spouse. Estate Resolu on Services include proceeds of a life or accidental death and dismemberment claim prepara on of documents and representa on at court proceedings needed to transfer the probate assets from the payment of $5,000 or more, backed by the financial strength estate to the heirs and comple on of correspondence necessary and claims paying ability of Metropolitan Life Insurance Company. TCA death claim payments relieve beneficiaries of the to transfer non‐probate assets. ERS covers par cipa ng plan a orneys’ fees for telephone and face‐to‐face consulta ons or need to make immediate decisions about what to do with a for the administrator or executor to discuss general ques ons lump‐sum check and enable them to have the flexibility to about the probate process. access funds as needed while earning a guaranteed minimum interest rate on the proceeds as they assess their financial WillsCenter.com8 situa ons. Call 1‐800‐638‐7283 for more informa on about Self‐service online legal document prepara on op ons available to you. Employees and spouses have access to WillsCenter.com, an online document service to prepare and update a will, living will, Will Prepara on7 power of a orney, funeral direc ve, memorandum of wishes or To help ensure your decisions are carried out HIPAA authoriza on form in a secure 24/7 environment at no When you enroll for supplemental term life coverage, you will addi onal cost. This service is available with all life coverages. automa cally receive access to Will Prepara on Services at no extra cost to you. Both you and your spouse will have unlimited Log on to www.willscenter.com to register as a new user. in‐person or telephone access to one of MetLife Legal Plans, Inc Portability na onwide network of 14,000+ par cipa ng a orneys for So you can keep your coverage even if you leave your current prepara on of or upda ng a will, living will or power of a orney.* When you use a par cipa ng plan a orney, there will employer Should you leave Fort Worth Independent School District for any be no charge for the services.* Like life insurance, a carefully reason, and your Basic, Supplemental and Dependent Term Life prepared will (simple or complex), living will and power of and Supplemental and Dependent Accidental Death and a orney are important. A will lets you define your most important decisions, such as Dismemberment insurance under this plan terminates, you will have an opportunity to con nue group term coverage who will care for your children or inherit your property. (“portability”) under a different policy, subject to plan design A living will ensures your wishes are carried out and protects your loved ones from having to make very difficult and state availability. Rates will be based on the experience of the ported group and MetLife will bill you directly. Rates may be and personal medical decisions by themselves. Also called higher than your current rates. To take advantage of this an “advanced direc ve,” it is a document authorized by feature, you must have coverage of at least $10,000 up to a statutes in all states that allows you to provide wri en maximum of $2,000,000. instruc ons regarding use of extraordinary life‐support Portability is also available on coverage you’ve selected for your measures and to appoint someone as your proxy or spouse and dependent child(ren). The maximum amount of representa ve to make decisions on maintaining coverage for spouse is $250,000; the maximum amount of extraordinary life‐support if you should become dependent child coverage is $25,000. Increases, decreases and incapacitated and unable to communicate your wishes. Powers of a orney allow you to plan ahead by designa ng maximums are subject to state availability. Generally, there is no minimum me for you to be covered by someone you know and trust to act on your behalf in the the plan before you can take advantage of the portability event of unexpected occurrences or if you become feature. Please see your employer or cer ficate for specific incapacitated details. Call 1‐800‐821‐6400 and a Client Service Representa ve will Please note that if you experience an event that makes you assist you. eligible for portable coverage, please call a MetLife * You also have the flexibility of using an a orney who is not representa ve at 1‐888‐252‐3607 or contact your employer for par cipa ng in the MetLife Legal Plans, Inc. network and being more informa on. reimbursed for covered services according to a set fee schedule. In that case you will be responsible for any a orney’s fees that Transi on Solu ons3 exceed the reimbursed amount. Assistance iden fying solu ons for your financial situa ons SM7 Transi on Solu ons provides assistance for important, me‐ Estate Resolu on Services (ERS) sensi ve benefit and financial decisions due to change in Personal service and compassion assistance to help probate your benefits including: and your spouse’s estates. Group Life Insurance Con nua on Op ons
Life Se lement Account5
70
Life and AD&D
Lump‐sum distribu ons Reduc on in benefits for ac ve or re red employees Benefits coordina on due to layoffs, merger, acquisi on or bankruptcy Define Contribu on Plan termina on Re ree Group Life elimina on
Addi onal Features This insurance offering from your employer and MetLife comes with addi onal features that can provide assistance to you and your family.
Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are fit by educa on, training or experience due to injury or sickness. The Total Disability must begin before age 60, and your waiver will begin a er you have sa sfied a 9‐month wai ng period of con nuous disability. The waiver of premium will end when you turn age 65, die, or recover. Please note that this benefit is only available a er you have par cipated in the supplemental term life plan for 12 months and it is not available on dependent coverage.
Premium Pay
Con nued premium payments during a total disability If you become totally disabled, your employer will con nue to Accelerated Benefits Op on make premium payments on your behalf for 12 months in order For access to funds during a difficult me If you become terminally ill and are diagnosed with 24 months to keep your Basic Life coverage ac ve. Your disability status or less to live, you have the op on to receive up to 80% of your will be determined by your employer. This provision allows life insurance proceeds. This can go a long way towards helping coverage for you as a disabled employee to be con nued as if your family meet medical and other expenses at a difficult me. you were s ll ac ve. Amounts not accelerated will con nue under your employer’s What’s Not Covered? plan for as long as you remain eligible per the cer ficate Like most insurance plans, this plan has exclusions. requirements and the group policy remains in effect. Supplemental and Dependent Life Insurance does not provide The accelerated life insurance benefits offered under your payment of benefits for death caused by suicide within the first cer ficate are intended to qualify for favorable tax treatment two years (one year for group policies issued in Missouri, North under Sec on 101(g) of the Internal Revenue Code (26 Dakota and Colorado) of the effec ve date of the cer ficate or 10 U.S.C.Sec 101(g)). an increase in coverage. This exclusionary period is one year for Accelerated Benefits Op on is not the same as long term care residents of Missouri and North Dakota. If the group policy was insurance (LTC). LTC provides nursing home care, home‐health issued in Massachuse s, the suicide exclusion does not apply to care, personal or adult day care for individuals above age 65 or dependent life coverage. The suicide exclusion does not apply with chronic or disabling condi ons that require constant to residents of Washington, or to individuals covered under a supervision. group policy issued in Washington. The Accelerated Benefits Op on is also available to spouses Please note that a reduc on schedule may apply. Please see insured under Dependent Life insurance plans. This op on is your employer or cer ficate for specific details. not available for dependent child coverage. Accidental Death & Dismemberment (AD&D) coverage Conversion complements your Supplemental Life insurance coverage and For protec on a er your coverage terminates helps protect you 24 hours a day, 365 days a year. You can generally convert your group term life insurance benefits to an individual whole life insurance policy if your Accidental Death & Dismemberment coverage terminates in whole or in part due to your re rement, Coverage Op ons termina on of employment, or change in employee class. Conversion is available on all group life insurance coverages. Please note that conversion is not available on AD&D coverage. This valuable coverage benefits beyond your disability or life insurance for losses due to covered accidents — including while If you experience an event that makes you eligible to convert commu ng, traveling by public or private transporta on and your coverage, please call 1‐877‐275‐6387 to begin the during business trips. MetLife’s AD&D insurance pays you conversion process. Please contact your employer for more benefits if you suffer a covered accident that results in paralysis informa on. or the loss of a limb, speech, hearing or sight, third degree burn, or brain damage or coma. If you suffer a covered fatal Waiver of Premiums for Total Disability (Con nued accident, benefits will be paid to your beneficiary. Protec on) 10
Offering con nued coverage when you need it most If you become Totally Disabled, you may qualify to con nue certain insurance. You may also be eligible for waiver of your supplemental term life insurance premium un l you reach age 65, die, or recover from your disability, whichever is sooner.
Supplemental AD&D Coverage Amounts for You Your Supplemental AD&D amount is equal to your Supplemental Term Life amount. *Child(ren)’s Eligibility: Dependent children ages from birth to 26, regardless of student status.
71
Life and AD&D Covered Losses This AD&D insurance pays benefits for covered losses that are the result of an accidental injury or loss of life. The full amount of AD&D coverage you select is called the “Full Amount” and is equal to the benefit payable for the loss of life. Benefits for other losses are payable as a predetermined percentage of the Full Amount and will be listed in your coverage in a table of Covered Losses. Such losses include loss of limbs, sight, speech and hearing, various forms of paralysis, brain damage and coma. The maximum amount payable for all Covered Losses sustained in any one accident is capped at 100% of the Full Amount.
Standard Addi onal Benefits Include Some of the standard addi onal benefits included in your coverage that may increase the amounts payable to you and/or defray addi onal expenses that result from accidental injury or loss of life are: Air Bag Seat Belt Common Carrier Child Care Center Child Educa on Spouse Educa on Hospitaliza on
What Is Not Covered by AD&D? AD&D insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infec on, unless caused by an external wound accidentally sustained or from food poisoning; suicide or a empted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medica on or seda ve, unless taken as prescribed by a doctor or an over‐the‐counter drug taken as directed; voluntary intake of alcohol in combina on with any drug, medica on or seda ve; war, whether declared or undeclared, or act of war, insurrec on, rebellion or ac ve par cipa on in a riot; commi ng or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or interna onal authority, except the United States Na onal Guard; opera ng, learning to operate, or serving as a member of a crew of an aircra ; while in any aircra for the purpose of descent from such aircra while in flight (except for self‐preserva on); or opera ng a vehicle or device while intoxicated as defined by the laws of the jurisdic on in which the accident occurs.
Addi onal Coverage Informa on How To Apply*
do not need to do anything. *All applica ons are subject to review and approval by Metropolitan Life Insurance Company. Based on the plan design and the amount of coverage requested, a Statement of Health may need to be submi ed to complete your applica on.
For Employee Coverage Enrollment in this Supplemental Term Life insurance plan is available without providing medical informa on as long as: For Annual Enrollment The enrollment takes place prior to the enrollment deadline, and You are con nuing the coverage you had in the last year, or You are reques ng to increase exis ng coverage by one increment, and the total amount of coverage does not exceed $250,000.
For New Hires The enrollment takes place within 31 days from the date you become eligible for benefits, and You are enrolling for coverage equal to/less than $250,000 If you do not meet all of the condi ons stated above, you will need to provide addi onal medical informa on by comple ng a Statement of Health form.
†
For Dependent Coverage
You must be covered in order to obtain coverage for your spouse and child(ren). Your spouse and dependent children do not need to provide medical informa on as long as: For Annual Enrollment The enrollment takes place prior to the enrollment deadline, and You are con nuing the coverage you had for your spouse and child(ren) in the last year You are reques ng to increase exis ng coverage for your spouse by one increment, and the total amount of coverage does not exceed $50,000. For New Hires The enrollment takes place within 31 days from the date you become eligible for benefits, and You are enrolling for spouse coverage equal to/less than $50,000 and enrolling for child(ren) coverage equal to/less than $15,000. If you do not meet all of the condi ons stated above, you will need to provide addi onal medical informa on by comple ng a Statement of Health form.
About Your Coverage Effec ve Date
You must be Ac vely at Work on the date your coverage Apply online at www.mybenefitshub.com/fortworthisd today! Be becomes effec ve. Your coverage must be in effect in order for sure to indicate your Beneficiary. your spouse and eligible children’s coverage to take effect. In addi on, your spouse and eligible child(ren) must not be home or Act Now During the Enrollment Period. hospital confined or receiving or applying to receive disability Note: If you do not wish to make a change to your coverage, you benefits from any source when their coverage becomes effec ve. 72
Life and AD&D If Ac vely at Work requirements are met, coverage will become effec ve on date of hire for Basic Life and on the first of the month following the receipt of your completed applica on for Supplemental and Dependent Life requests that do not require addi onal medical informa on. A request for your amount that requires addi onal medical informa on and is not approved by the date listed above will not be effec ve un l the later of the date that no ce is received that MetLife has approved the coverage or increase if you meet Ac vely at Work requirements on that date, or the date that Ac vely at Work requirements are met a er MetLife has approved the coverage or increase. The coverage for your spouse and eligible child(ren) will take effect on the date they are no longer confined, receiving or applying for disability benefits from any source or hospitalized.
Who Can Be A Designated Beneficiary? You can select any beneficiary(ies) other than your employer for your Basic and Supplemental coverages, and you may change your beneficiary(ies) at any me. You can also designate more than one beneficiary. You are the beneficiary for your Dependent coverage.
This informa on was wri en as a supplement to the marke ng of life insurance products. Tax laws rela ng to accelerated benefits are complex and limita ons may apply. You are advised to consult with and rely on an independent tax advisor about your own par cular circumstances. Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and condi ons of the contract between MetLife and Fort Worth Independent School District and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the booklet cer ficate. Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminate when your employment ceases, when your Life and AD&D contribu ons cease, or upon termina on of the group contract. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent or when your coverage terminates. Should your life insurance coverage terminate for reasons other than non‐payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.
1 ‐ (Not available in NY) Grief Counseling services are provided through an agreement with LifeWorks US Inc. LifeWorks is not an affiliate of MetLife, and the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a na onwide network of over 30,000 counselors. Counselors have master’s or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domes c issues, paren ng issues, or marital/rela onship issues (other than a finalized divorce). For such issues, members should inquire with their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and un l such loss has occurred. Services are not available in all jurisdic ons and are subject to regulatory approval. Not available on all policy forms. 3 ‐ MetLife administers the programs, but has arranged for specially‐trained financial professionals offer financial educa on and, upon request, provide personal guidance to employees and former employees of companies providing these programs through MetLife. 5 ‐ The TCA is not insured by the Federal Deposit Insurance Corpora on or any government agency. The assets backing TCAs are maintained in MetLife’s general account and are subject to claims of MetLife’s creditors. MetLife bears the investment risk of the assets backing TCAs, and expects to receive a profit. Regardless of the investment experience of such assets, the interest credited to TCAs will never fall below the guaranteed minimum rate. Guarantees are subject to the financial strength and claims paying ability of MetLife. 8 ‐ WillsCenter.com is a document service provided by SmartLegalForms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not affiliated with MetLife and the WillsCenter.com service is separate and apart from any insurance or service provided by MetLife. The WillsCenter.com service does not provide access to an a orney, does not provide legal advice, and may not be suitable for your specific needs. Please consult with your financial, legal, and tax advisors for advice with respect to such ma ers. 10 ‐ The Accelerated Benefits Op on is subject to state availability and regula on. The accelerated life insurance benefits offered under your cer ficate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxa on.
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TEXAS LIFE
Permanent Life
About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.
YOUR BENEFITS PACKAGE
Experts recommend at least
x 10 your gross annual income in coverage when purchasing life insurance.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 74 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Permanent Life Life Insurance Highlights for the Employee
c.
Flexible Premium Life Insurance to Age 121 Policy Form PRFNG-NI-10 Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually cost more and decline in death benefit. The policy, PURELIFE-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: •
High Death Benefit. High Death Benefit. With one of the highest death benefits available at the worksite,1 PURELIFEplus gives your loved ones peace of mind.
•
Minimal Cash Value. Minimal Cash Value.Designed to provide a high death benefit at a reasonable premium, PURELIFE-plus provides peace of mind for you and your beneficiaries while freeing investment dollars to be directed toward such taxfavored retirement plans as 403(b), 457 and 401(k).
•
Long Guarantees. 2 Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time.3
•
Refund of Premium. Unique in the marketplace, PURELIFEplus offers you a refund of 10 years’ premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)
•
Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.) (Form ICC07-ULABR-07 or Form Series ULABR-07
c. Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation therapy, dialysis treatment, or treatment for alcohol or drug abuse?
Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1
Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2012 Guarantees are subject to product terms, exclusions and limitations and the insurer’s claims -paying ability and financial strength. 3 After the guaranteed period, premiums may go down, stay the same, or go up. 4 Coverage and spouse/domestic partner eligibility may vary by state. Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships, and legally recognized familial relationships. Coverage not available on children and grandchildren in Washington. 2
DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.
You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, children and grandchildren by answering just 3 questions:4 During the last six months, has the proposed insured: a. Been actively at work on a full time basis, performing usual duties? b. b. Been absent from work due to illness or medical treatment for a period of more than five consecutive working days?
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Permanent Life Life insurance you can keep • • • •
High death benefit Fully portable Permanent Coverage Very affordable
Permanent Life Insurance Coverage
the District of Columbia. We operate out of our home office in Waco, TX. Our Vision is to be known and respected as the leading provider of voluntary permanent life insurance to employees and their families, through their employers, with policies that are easy to sell and buy.
Product Highlights
High Death Benefit With one of the highest death benefits available at the worksite, PURELIFE-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely. Minimal Cash Value Designed to provide a high death benefit, PURELIFE-plus does Why Permanent Life Insurance Is So Important not compete with the cash accumulation in your employerPURELIFE Features: sponsored retirement plans. Long Guarantees • It can be an ideal complement to group term and any Enjoy the assurance of a policy that has a guaranteed death optional term life insurance your employer might provide. benefit to age 121 and level premium that guarantees coverage • Unlike group and optional term, this policy has a death for a significant period of time (after the guaranteed period, benefit guaranteed to age 121, as long as you pay the premiums may go down, stay the same, or go up). necessary premiums, even when you retire or change jobs. Refund of Premium Even if group or optional term is portable, it typically rises in Unique in the marketplace, PURELIFE-plus offers you a refund of cost and reduces in benefit at retirement. 10 years’ premium, should you surrender the policy if the • This policy is available to you, your spouse, your minor premium you pay when you buy the policy ever increases. children, even your minor grandchildren.† (Conditions apply.) Accelerated Death Benefit Rider • Premiums are payable through the convenience of payroll Should you be diagnosed as terminally ill with the expectation of deduction. • You select the coverage amount and / or premium that best death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, meets your needs. minus a $150 ($100 in FL) administrative fee. This valuable living • The application process is quick and simple. benefit gives you peace of mind knowing that, should you need • You can apply for coverage based on your answers to just three work- and health- related Express Issue underwriting it, you can take the large majority of your death benefit while still alive. (Conditions apply.) questions. • This policy offers a significant death benefit at an affordable Portable Coverage is guaranteed as long as required premiums are paid, premium. even after you retire or terminate employment. An ideal complement to any group term and optional term life insurance your employer might provide, PURELIFE-plus is the life insurance you keep, even when you change jobs or retire. Its high death benefit and long guarantees provide peace of mind for you and your family.
Who is eligible? Employees and their spouses, minor children, even your minor grandchildren are eligible to apply for coverage.†
How do I enroll? Buying life insurance is a personal decision, and as such, you will have the opportunity to consult with an enrollment representative. Should you decide to apply for coverage, the enrollment representative will guide you through the application process. Our contingent guaranteed issue allows you to apply for generous amounts of coverage by answering just 3 work- and health- related questions.
Who is Texas Life? Texas Life was founded in 1901 and is the oldest life insurance company domiciled in Texas. We are admitted in 49 states and 76
Sample Weekly Rates—Non-Tobacco 25 Years Old 35 Years Old 45 Years Old 55 Years Old
Face Value (3) Guaranteed Age (4) $25,000 $50,000 $100,000 $1.97 $3.58 $6.81 63 $2.72 $5.08 $9.81 64 $5.54 $10.74 $21.12 74 $12.35 $24.35 $48.35 86
(1) Voluntary and Universal Whole Life Products, Eastbridge Consulting Group,October 2012 (2) Guarantees are subject to product terms, exclusions and limitations and the insurer’s claims-paying ability and financial strength. (3) Insurance coverage is subject to evidence of insurability. Suicide and contestable clauses apply. (4) Age to which coverage is guaranteed at Table Premium. After the Guaranteed Period, premiums may go down,stay the same or go up
Permanent Life Information About PURELIFE-plus Minimal Cash Values Buy this policy for its life insurance protection, not its cash value. The primary benefit is life insurance. Payment of the Table Premium produces a small cash value (Benchmark Cash Value). Permanent Life Insurance Coverage Unlike group term life insurance, PureLife-plus is a personally owned, permanent individual life insurance policy to age 121 that can never be canceled or reduced as long as you pay the necessary premiums, even if your health changes. Guaranteed Period Continuous, timely, and uninterrupted payment of the Table Premium guarantees coverage for the Guaranteed Period stated in the policy. Texas Life (We) cannot legally predict the premium required to continue coverage after the Guaranteed Period. It may be lower, the same, or higher than the Table Premium. However, if the premium to continue coverage is ever higher, We guarantee a limited right to a partial refund of premium. Guaranteed Limited Right to Partial Refund of Premium If a premium higher than the Table Premium is ever required to continue coverage after the Guaranteed Period, you have the choice to: (a) pay the higher premium(s) required to continue coverage; or, (b) surrender the policy and receive a partial refund of premium equal to 120 times the minimum monthly premium due at issue (10 years worth of Table Premium). You are eligible for this refund if the actual cash value equals or exceeds the Benchmark Cash Value and you have taken no prior partial surrenders. Conditions apply. Accelerated Death Benefit For no added premium, the policy includes an Accelerated Death Benefit Due to Terminal Illness Rider (ICC07-ULABR-07 or Form Series ULABR-07) If the insured becomes terminally ill you may elect to claim an accelerated benefit while the insured is still alive in lieu of the insurance proceeds payable at death. In most states the single sum benefit is 92% (84% in IL) of the insurance proceeds. There is also an administrative fee of $150 ($100 in FL).This is not a longterm care benefit. Terminal Illness (or Condition) is an injury or sickness diagnosed and certified by a qualifying physician that, despite appropriate medical care, is reasonably expected to result in death within 12 months (24 months in IL). We can, at our expense, request the opinion of a physician We choose. A 90day exclusion period applies unless the terminal illness results from accidental bodily injury (30 days in CT, IL, LA, MD, UT; 0 days in OR, SC) Other conditions and limitations apply. Pay premiums faithfully. The rider terminates if the policy ever lapses for non-payment of premium, even if the policy is later reinstated. The right to accelerate benefits under this rider does not extend to any Child Term Life Insurance Rider. However, if the accelerated benefit is paid, the Child Rider becomes paid-up term insurance to each insured child’s age 25. Payment of the Accelerated Death Benefit terminates the policy and all optional benefits/riders without further value.
Child Term Life Insurance Rider In lieu of an individual policy on each child, if the primary insured is age 59 or less you may apply for a Child Term Life Insurance Rider for $10,000. It insures the primary insured’s children and step-children who are ages 15 days through age 18 at the time of application. Children thereafter born to or adopted by the primary insured are covered 15 days after birth. Coverage continues to age 25. Coverage terminates at the primary insured’s age 65. Coverage on a step-child ceases upon the primary insured’s divorce from the step-child’s natural or adoptive parent. If the primary insured dies, coverage is paid-up to the earlier of the insured child’s age 25 or the Contract Anniversary Date on which the primary insured’s Attained Age would have been 65. (ICC07-ULCL-CIR07 or Form Series ULCL-CIR-07) Important Notice The insurance proceeds, cash values, and loan values will all be reduced to zero and will no longer be payable if Texas Life pays the Accelerated Death Benefit. The benefit under this rider is intended to qualify for favorable income tax treatment under the Internal Revenue Code of 1986. If the benefit qualifies for such favorable tax treatment, it will be excludable from your income and not subject to federal income taxation. Receipt of the benefit may affect your, your spouse’s or your family’s eligibility for Medicaid, Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance programs. Tax and public benefit laws relating to acceleration of life insurance benefits are complex. You should consult a qualified tax or legal advisor or social services agency to determine how receipt of such payment will affect you and your family. Neither Texas Life nor its agents are authorized to give tax or legal advice. Interim Insurance Interim insurance will be in force on the application date if these conditions are met: (1) the insurance is purchased through automatic deduction; (2) the deduction authorization is signed; and, (3) the proposed insured is insurable at standard rates under our rules and usual practice. Interim insurance remains in effect until the earlier of: (a) the Policy Date; (b) the date we decline the application; (c) the date We notify the applicant that s/he is ineligible for interim insurance; or, (d) the 180th day after the application date. In Kansas, clauses (3) and (d) do not apply, and clauses (b) and (c) apply only when we refund all premiums. This is a summary only. Policy provisions prevail. This information is not a contract or an offer to contract. Policy Form PRFNG-NI-10 Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships, and legally recognized familial relationships. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. PURELIFE-plus is not available in NJ, NY, or PA. Texas Life is licensed to do business in the District of Columbia and every state but New York. 14M080-C 1054 (exp0616) Policy Form PRFNG-NI-10 † Coverage not available on children and grandchildren in Washington.
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CHUBB YOUR BENEFITS PACKAGE
Accident
About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-soserious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.
2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or
usually live paycheck to paycheck.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 78 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Accident No one plans on getting injured… but just in case. we've got you covered.
Monthly Premiums
GOLD
DIAMOND
Employee Only
$9.40
$16.48
You do everything you can to stay active and healthy, but accidents happen every day, including sports-related accidents. An injury that hurts an arm or a leg can hurt your finances too. That's where Chubb Accident can help.
Employee + Spouse
$17.16
$30.12
Employee + Child(ren)
$19.32
$33.64
Family
$27.08
$47.28
Chubb Accident pays cash benefits directly to you or anyone you choose regardless of any other coverage you have. And Chubb Accident pays extra benefits for injuries resulting from participating in organized sports. Let Chubb Accident help take care of your bills so you can take care of yourself and your family.
Schedule of Benefits—No-occupational Coverage Gold & Diamond Plans Initial Care
GOLD
DIAMOND
$120
$200
$1,000
$2,000
Emergency Room
$100
$200
Initial Doctor's Office Visit
$50
$100
Urgent Care
$50
$100
Crown
$200
$400
Extraction
$50
$100
$500
$1,500
$1,000
$3,000
Chubb Accident Benefits include First Accident Pays you $100 soon after you report your first claim for covered benefits! If you get injured, we can begin processing your claim right over the phone so you can get cash fast. Sports Package Your benefits increase 25%, up to $1,000 per person per year, for injuries resulting from participating in organized sports! Playing sports can lead to injuries and unwelcome expenses. We'll increase your benefits to help pay those expenses Rehabilitation Package We pay cash benefits for Admission, Daily Confinement and Recovery! Whether you are released to a Rehabilitation Center following a hospital stay or you recover at home, we pay a daily recovery benefit to help with your transition.
Ambulance
Here’s How Accident Benefits Work:
ICU Admission
Chubb Accident helps pay for unexpected costs of accidental injury. If your child breaks a leg at soccer practice here's how benefits may stack up: The Sports Package increases the total benefit payment by $573.
Rehabilitation Admission
$500
$1,500
Hospital Confinement per day, up to 365 days
$150
$250
ICU Confinement per day, up to 30 days
$300
$500
Rehabilitation Confinement per day, up to 30 days
$90
$150
Recovery per day, up to seven days
$50
$100
Abdominal or Thoracic Surgery
$750
$1,500
Appliances
$75
$100
Blood, Plasma, Platelets
$200
$300
Chiropractic Care per visit, up to three visits
$25
$25
Concussion
$60
$100
First Accident Ambulance ER Visit X-Ray Fracture Crutches Physical Therapy Follow-up Visits Subtotal PLUS Sports Package Total Payment
$100 $200 $200 $40 $1,000 $100 $500 $150 $2,290 $573 2$2,863
This example is for illustrative purposes only and should not be compared to an actual claim. Whether an injury is covered depends on the circumstances of the loss. Refer to the certificate of insurance or policy for terms and conditions.
Ground Air
Emergency Dental
Hospital and Rehabilitation Hospital Admission
Follow-up Care & Treatment
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Accident Follow-up Care & Treatment
GOLD
DIAMOND
Follow-up Treatment per visit, up to three visits
$25
$50
Lodging for treatment 100 miles or more away; per night, up to 30 nights
$100
$150
Major Diagnostic Exam (CT, MRI, etc.)
$100
$200
$2,500
$2,500
Outpatient Surgery Facility
$25
$25
Physical Therapy per visit up to 10 visits
$25
$50
Prosthetics
$500
$1,500
Tendon, Ligament, or Rotator Cuff Surgery
$400
Organ Loss
Additional Benefits
GOLD
DIAMOND
First Accident once per policy
$100
$100
Sports Package Benefits are 25% higher when accident is due to participation in organized sports. Up to $1,000 per person per year. Accidental Death Employee & Spouse
$20,000
$50,000
Child
$4,000
$10,000
Employee & Spouse
$20,000
$50,000
Child
$10,000
$25,000
On or after Age 70
50%
50%
$750
Family Care for each child in a child care center; per day, up to 30 days
$25
$25
$50
$50
Catastrophic Accident Prior to Age 70
Transportation for treatment 100 miles or more away; per trip, up to three trips
$300
$600
Wellness per person, once per year 90 days waiting period
X-ray
$20
$40
Features
GOLD
DIAMOND
Level 1
$750
$1,000
Level 2
$1,500
$2,000
Level 3
$7,500
$10,000
Injuries Burns
Skin raft
25% of the burn benefit
Coma
$7,500
$12,500
Open reduction, up to…
$3,600
$4,800
Closed reduction, up to…
$1,800
$2,400
$200
$300
Open reduction, up to…
$5,000
$7,000
Closed reduction, up to...
$2,500
$3,500
Herniated Disc
$400
$750
Knee Cartilage—Torn
$400
$750
$20 - $300
$30 - $500
Loss of Hands, Feet or Sight
$10,000
$20,000
Loss of Fingers or Toes
$1,200
$2,000
Dislocations
Eye Fractures
Lacerations
You do everything you can to keep your family safe, but accidents happen, and when they do, it’s good to know Chubb has you covered. Date of Application Coverage Coverage becomes effective as soon as your application is signed, you have authorized payment and the Initial Eligibility requirements are met. Guaranteed Issue No medical history is required for coverage to be issued. Guaranteed Renewable Your coverage cannot be cancelled as long as your premiums are paid as due. Fully Portable You can keep your coverage even if you change jobs or retire. HSA Compatible
Initial Eligibility Employee • Actively employed working at least 10 hours per week • Ages 18 and up Spouse • Ages 18 and up Dependent children/grandchildren • Ages to 26 • No student status required • Coverage will continue for incapacitated dependent children regardless of age.
Benefits may vary by state. Benefits are paid once per accident unless otherwise noted.
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Accident E
Accident Benefits Summary Name: Type of Coverage: _________________
Employee Employee + Spouse Employee + Child(ren) Family
Payroll Deduction: $________________
Exclusions & Limitations This is Accident-Only Insurance. No benefits will be paid for services rendered by a member of the Immediate Family of a Covered Person. No benefits will be payable for sickness or infection including physical or mental condition that is not caused solely by or as a direct result of a Covered Accident. No benefits will be paid for an injury that is caused by, contributed to, or occurs as a result of a covered person's: Being intoxicated, or under the influence of alcohol or any narcotic or other prescription drug unless administered on the advice of a Physician and taken according to the Physician's instructions (the term "intoxicated" means the minimum blood alcohol level required to be considered operating an automobile under the influence of alcohol in the jurisdiction in which the accident occurred); Participating in an illegal activity or attempting to commit or actually committing a felony ("felony" is as defined by the law of the jurisdiction in which the activity takes place); Committing or attempting to commit suicide or intentionally injuring himself or herself; Having dental treatment, except for such care or treatment due to injury to sound natural teeth within twelve (12) months of the Covered Accident; Being exposed to war or any act of war, declared or undeclared, or serving in any of the armed forces or units auxiliary thereto; or Participation in any contest using any type of motorized vehicle. No benefits will be paid for an injury incurred while working for pay or profit. This is a supplement to health insurance and is not a substitute for Major Medical, or other minimal essential, coverage. This document is a brief description of Form Nos. Cl4059R or 14185 (or applicable state version). Refer to your certificate of insurance or policy for specific details about benefits, exclusions and limitations.
Avery was born 14 weeks early weighing only 1lb 5 oz. Avery spent 234 days in Cook Children’s Neonatal Intensive Care Unit (NICU), with specialized care that helped Avery celebrate her first birthday—a milestone her parents weren’t always sure would be possible. For Avery, the NICU was the first stop on a long medical journey. Avery went home dependent on oxygen and a feeding tube and continued to receive care and support form our NEST Development Follow-Up Center. Support from programs like Benefits that Benefit Children, a voluntary benefit cause marketing program, enable Cook Children’s to provide the highly specialized intensive care services and attention that medically fragile babies, like Avery, need. Benefits That Benefit Children provides donations to Cook Children’s when companies like yours offer certain best-in-class voluntary benefits from top-ranked providers. Through the Benefits That Benefit Children* program, you have an opportunity to help Cook Children’s in their ongoing commitment to saving children’s lives. Benefits That Benefit Children, in partnership with Combined Insurance Company of America, will donate $10 to Cook Children’s for each qualified employee attending an employee-benefit enrollment meeting. †By attending the meeting, the contribution is made without any obligation to purchase coverage. *Benefits That Benefit Children is a cause marketing program, created by National Benefit Partners. †Combined Insurance Company of America, a Chubb company, will make a $10 donation to Cook Children’s for each qualified employee that attends an employee-benefit enrollment meeting even if no products are purchased. No employee purchase of enrollment necessary. Purchase of a product will not increase the charitable donation.
Meet Avery She continues to defy the odds In neonatology, it's the little things that matter. That's why Cook Children's nationally recognized Level IV NICU provides the highest level of care. But our care and attention doesn't end there. The Cook Children's NEST Developmental Follow-up Center, created in 2013 with donor support, helps babies and their family's transition from hospital to home. The NEST Center begins supporting the family before a baby is discharged from the NICU, and then monitors the child's growth and development through 5 years of age giving our babies the best chance to soar.
Learn More About Avery: https:// www.facebook.com/64714594575/posts/101555033691199576 81
TEXAS LEGAL YOUR BENEFITS PACKAGE
Legal Services
About this Benefit Having an affordable, qualified lawyer on your side can be an invaluable asset. Legal plans provide valuable benefits that cover the most common legal needs you may encounter - like creating a standard will, living will, healthcare power of attorney or buying a home. This plan also provides access to quality law firms for advice, consultation and representation. Benefit is not payroll deducted. To enroll, click LEGAL SERVICES on the Fort Worth ISD benefits portal, and select the QUICK LINK that says Enroll Now.
$1,500 Is the average cost of a basic will and estate planning package. The average yearly premium paid by Texas Legal Members is only $300.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 82 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Legal Services Texas Legal Legal Insurance Built for Texans Every year, 70 percent of people have a legal problem and need a lawyer’s help. Estate planning, Identity theft, bankruptcy, divorce, DWIs - the list goes on and on. But with the average lawyer charging $250 an hour, many people can’t afford the protection they need and deserve.
Save Money and Protect Your Family with Legal Insurance From Texas Legal Legal insurance from Texas Legal lets you save money on legal services that everyone needs, such as estate planning, while protecting you from serious legal challenges that can come with life’s unknowns, including family, civil, consumer, and criminal issues. Texas Legal is a non-profit founded by the State Legislature of Texas over 40 years ago. Our charter is simple - protect everyday Texans from financial hardship that can come with legal challenges. Available only to Texans, we offer the most comprehensive legal insurance plan on the market. As a member of Texas Legal, you can get high-quality legal help without the high price tag.
How You’ll Save With Texas Legal:
Our Legal Insurance Plans Cover:
•
✔ ✔ ✔ ✔ ✔
• • •
PROBLEM: You need a will, but it costs too much. SOLUTION: A Texas Legal membership covers estate planning 100%, plus dozens of other legal issues $1,500 - the average cost of a basic will and estate planning package $300 - the average yearly premium paid by Texas Legal Members
Estate Planning Divorce Bankruptcy Consumer Law Criminal Defense
And Much More!
SAVED: $1,200 GAINED: Priceless Peace of Mind.
Texas Legal’s Vital Statistics: •
Non-profit Founded in 1972
•
Protects Tens of Thousands of Texans
•
Built by the Lawyers of Texas to Help Texans
•
Created and Endorsed by State Bar of Texas
•
Over 500 Texas Attorneys In Network
•
Most Comprehensive Legal Plan on the Market
“ Texas Legal has saved us thousands of dollars and gives me peace of mind not to worry about things. When I called for help on my last problem, I felt like I had the event under my control.” ~ Charlotte R. Texas Legal Member
Choose the Texas Legal Plan that Best Meets Your Needs: Coverages*
Select Plan
Preferred Plan
$10/$15 $100/$150
$20/$30 $195/$290
Estate Planning
✔
✔
AllClear ID® Identity Theft Monitoring
✔
✔
AllClear ID® Identity Theft Restoration
✔
✔
Monthly Annually
Family Law Divorce -OR- Modification/Establishment or Enforcements Bankruptcy Chapter 7 -OR- Chapter 13
10 Hours Covered 25% Discount
✔
✔ 83
Legal Services Coverages*
Select Plan
Preferred Plan
Traffic Tickets
25% Discount
✔
—
✔
Family Immigration Assistance
25% Discount
✔
Prenuptial or Postnuptial Agreement
25% Discount
✔
Defense of Misdemeanor Charge
25% Discount
✔
Defense of DWI/DUI
25% Discount
✔
Adoption
25% Discount
✔
8 Hours Covered
✔
Defense of Insanity or Infirmity
25% Discount
✔
Defense of Juvenile/Children's Court
25% Discount
✔
Habeas Corpus
25% Discount
✔
Defense of Felony Charge
25% Discount
✔
Defense of Driving Privileges
25% Discount
✔
General Legal Services
2 Hours Covered
6 Hours Covered
Consumer Protection
Consultations & Negotiations Only
✔
✔
✔
2 Consultations Covered
4 Consultations Covered
Probate Proceeding
25% Discount
✔
Residential Real Estate Transaction
25% Discount
✔
Expunction & Order of Nondisclosure
25% Discount
✔
Public Intoxication
25% Discount
✔
Guardianship of Adult or Minor
25% Discount
✔
Protective Order
25% Discount
✔
✔
✔
Financial Counseling
Defense of Civil Action
Uncontested Name Change Attorney Consultation
Legal Access Services
*Limitations and exclusions apply. This information is for illustrative purposes only and is not a contract. Benefits may be subject to limitations and exclusions. For terms, benefits or exclusions, please see plan documents. Don’t risk expensive legal fees or put off legal issues another day. Visit TexasLegal.org and become a member today or Call 1-800252-9346. 84
Legal Services Texas Legal Membership Advantages
• • • • •
Loan Agreements Real Estate Social Security/Disability Tax Law Financial Counseling
As a Member, you are joining thousands of Texans that benefit from legal coverage made available by Texas Legal. Our plans offer freedom of choice to choose an attorney for legal services when you need it the most. And when you choose a Participating Attorney, we will pay the attorney directly, with no copays or CRIMINAL LAW deductibles. We’ve been helping Texans like you for over 40 Criminal law covers a range of activities that vary in severity. years! Typical issues include matters of constitutional law, juvenile crimes, felonies, and more. Areas include: What’s Covered? • DWI/DUI (Defense) From life events to unexpected events, Texas Legal has you • Expunge/Seal Records covered. A legal benefits plan provided by Texas Legal is like • Felony (Defense) • Habeas Corpus homeowners insurance – you may never have to use the full • Insanity/Infirmity (Defense) array of benefits, but comprehensive coverage is available in • Jail Release case the unexpected happens. • Juvenile Court (Defense) • License Suspension - Revocation (Defense) • Misdemeanor (Defense) Texas Legal Preferred Plan • Public Intoxication • Traffic Tickets Texas Legal membership offers benefits across most areas
of law, including:
CONSUMER LAW
ESTATE PLANNING
Consumer law covers issues like breach of contract, as well as laws pertaining to common issues of consumer fraud. Areas include: • Civil Action (Defense) • Consumer Protection • Contracts • Creditors Rights & Collections • Identity Theft Restoration • Identity Theft Monitoring
MISCELLANEOUS
FAMILY LAW Family law encompasses matters such as adoption, divorce, custody, and child support. Areas include: • Adoption • Divorce • Establish a Family Court Order (Child Support, Custody, Visitation) • Guardianship • LGBT-specific Family Law • Modify/Enforce Family Court Order (Child Support, Custody, Visitation) • Prenuptial or Postnuptial Agreements • Name Change • Family Immigration Assistance • Protective Orders • Grandparents’ Rights
FINANCIAL LAW Financial law pertains to personal money issues. Areas include: • Chapter 7 Bankruptcy • Chapter 13 Bankruptcy • Foreclosures
Estate planning is primarily focused on inheritance planning, but also pertains to charitable planning, incapacity planning, and special needs planning. Areas include: • Powers of Attorney • Probate • Trusts • Wills/Codicils
There’s a wide range of legal issues that don’t fall into a specific legal category but are common, such as: • Document Preparation • Employment Law (limited to Independent Policies only) • Tenant Rights • Mediation • Medicaid/Medicare • Veteran's Benefits • Consultation • Legal Access Telephone Assistance
Texas Legal Select Plan How Texas Legal Works •
•
Become a Member Choose a plan and pay an affordable monthly premium. Find an Attorney Whenever you need legal help, we’ll help you find a Texas Legal attorney close to you who can assist with your legal issue.
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Legal Services • •
•
Meet with Your Attorney You choose which attorney you want to work with and meet with them to resolve your legal problem. Problem Solved! Whether it’s writing a will, declaring bankruptcy or defending yourself in small claims court, your attorney will provide you with professional, helpful service. Attorney Fees Paid Your attorney bills Texas Legal for their time and we pay them directly. No deductibles or co-pays!
Texas Legal membership offers benefits across most areas of law, including:
CONSUMER LAW Consumer law covers issues like breach of contract, as well as laws pertaining to common issues of consumer fraud. Areas include: • Civil Action (Defense) • Consumer Protection
Frequently Asked Questions Do you provide attorney recommendations? Referral services are highly regulated in Texas, which prohibits us from being able to recommend any particular attorney. You can locate a Texas Legal Participating Attorney by using our Attorney Finder at www.TexasLegal.org. What cost can I expect when I meet with an attorney? Your policy will pay for the attorney’s time to work on your legal matter up to certain limitations. You will not be responsible for any copays or deductibles. Please refer to the Certificate of Coverage for details. Please note, you may be responsible for any incidentals such as court costs, filing fees, copy fees, postage fees, and/or travel costs.
FAMILY LAW
What about non-covered legal matters? Can I still use a Texas Legal Participating Attorney? Yes. If the legal matter is not covered, you may still use a Texas Legal Participating Attorney. However, the attorney will provide you a written contract for services provided and may bill you at a 25% discounted rate of their usual and customary rates.
Family law encompasses matters such as adoption, divorce, custody, and child support. Areas include: • Divorce • Establish a Family Court Order (Child Support, Custody, Visitation) • LGBT-specific Family Law • Modify/Enforce Family Court Order (Child Support, Custody, Visitation) • Name Change
When are my benefits available? Do any benefits have waiting periods? Texas Legal Preferred Plan Most benefits are available the first date of your policy. Bankruptcy has a 90-day waiting period. Divorce, modification, enforcement, or establishment of a family court order all have a six-month waiting period.
Texas Legal Select Plan Most benefits are available the first date of your policy. Divorce, Estate planning is primarily focused on inheritance planning, but modification, enforcement, or establishment of a family court also pertains to charitable planning, incapacity planning, and order all have a six-month waiting period. special needs planning. Areas include: • Powers of Attorney Do you cover pre-existing matters? • Trusts No. You must be a member of Texas Legal at the time the legal • Wills/Codicils matter occurs.
ESTATE PLANNING
MISCELLANEOUS There’s a wide range of legal issues that don’t fall into a specific legal category but are common, such as: • General Consultation • Legal Access Telephone Assistance • Document Preparation & Review • Medicaid/Medicare • Veteran’s Benefits
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Are all benefits available to each member of my family? Texas Legal Preferred Plan Most benefits are available to each family member listed on your policy. However, the following are only available to the Named Policyholder: Residential Real Estate Transactions, Family Immigration Assistance, Identity Theft Monitoring, Divorce, Modification, Enforcement, or Establishment of a family court order. Please note: Once you or your dependent uses a benefit, you cannot use that same benefit again until your plan year renews.
Legal Services Texas Legal Select Plan Are all benefits available to each member of my family? Most benefits are available to each family member listed on your policy. However, the following are only available to the Named Policyholder: Divorce, Modification, Enforcement, or Establishment of a family court order. Please note: Once you or your dependent uses a benefit, you cannot use that same benefit again until your plan year renews. Can I use this plan for my business? No. Texas Legal benefit plans are only available for personal or individual legal matters, not for business-related matters. Can I use my plan outside of Texas? Texas Legal does have out-of-network benefits when using a nonparticipating attorney. Contact us for more information.
Limitations and exclusions apply. Legal insurance products/memberships are provided by Texas Legal and are in compliance with the provisions of the Texas Department of Insurance. Services are only available through membership in Texas Legal. Membership does not cover previously established or filed legal issues or disputes. This information is for illustrative purposes only and is not a contract. For terms, benefits or exclusions, see your plan documents. If you have questions or would like to join, call Member Services toll free at 1-800-252-9346
Access to the best legal coverage in the Lone Star State is at your fingertips!
Go online to www.TexasLegal.org and use our Attorney Finder to choose a trusted lawyer from our network of Participating Attorneys. Texas Legal 1-800-252-9346 members@texaslegal.org www.TexasLegal.org
7500 Rialto Boulevard Building One, Suite 120 Austin, Texas 78735
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FORT WORTH ISD
YOUR YOUR BENEFITS BENEFITS PACKAGE PACKAGE
January Savings Plan
About this Benefit The January Savings Plan provided by your employer is a way to set aside funds from your paycheck to offset unexpected holiday costs. During your open enrollment, you can choose a monthly amount to be deducted from your pay check on a regular basis through the scheduled date.
Tips for Saving Money
• • • • • •
Save your loose change. Keep track of your spending. Never purchase expensive items on impulse. Create a budget. Aim for short-term savings goals Save money by buying items online, in bulk.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 88 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
January Savings Plan
Voluntary enrollment in the January Savings Plan will only be allowed during Benefits Open Enrollment. No interest will be earned on the deduction amount. Deductions will be taken each payday as shown below:
Monthly Dates September 28, 2020 October 28, 2020 November 20, 2020 December 17, 2020
Semi-Monthly Dates September 15, 2020 September 30, 2020 October 15, 2020 October 30, 2020 November 13, 2020 November 30, 2020 December 15, 2020
The minimum monthly deduction is $10.00. If a semi-monthly employee selects $10.00 monthly, $5.00 will be taken each pay period marked in the table above. If a monthly employee selects $10.00 monthly, $10.00 will be taken each pay period marked in the table above. Disbursement of the total amount deducted through December will be direct deposited on January 8, 2021. There will be NO early disbursements of funds. Funds in this account will NOT incur interest.
89
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 90 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd
Medical Transport MASA MTS provides peace of mind. Any Ground. Any Air. Anywhere
BENEFIT
EMERGENT PLUS $14/mo. or $160/yr
PLATINUM $39/mo. or $468/yr
Emergent Ground Transportation
U.S./Canada
U.S./Canada
Emergent Air Transportation
U.S./Canada
U.S./Canada
Non-Emergent Air Transportation
U.S./Canada
Worldwide
Repatriation
U.S./Canada
Worldwide
Coverage against unplanned medical emergencies is surprisingly affordable. Be prepared for the unexpected with a MASA membership. No matter where you live, you could have access to vital emergency medical transportation for a minimal monthly fee. That membership could one day save your life, and, every day, it will give you peace of mind like nothing else.
MASA MTS protects you when your insurance falls short. • • • • •
One low fee for peace of mind for emergent transport costs No deductibles Easy claim process No health questions Anyone can join
Facts You Should Know • • • •
Emergent Ground Ambulance transports can easily surpass $2,000 and can reach as high as $5,000. Emergent Air Ambulance transports frequently cost more than $40,000, reaching as high as $70,000. If you are in need of specialized care and can be transported on an non-emergent basis, it is common for a medically equipped plane to cost more than $20,000. Most people assume that their health insurance will cover most, if not all, of the costs for these transports. Usually, the opposite is true, leaving you with financially crippling bills.
Escort Transportation
Worldwide
Mortal Remains Transportation
Worldwide
Visitor Transportation
BCA*
Minor Children/ Grandchildren Return
BCA*
Vehicle Return
BCA*
Pet Return
BCA*
Organ Retrieval
U.S. Only
Organ Recipient Transportation
U.S. Only
*Basic Coverage Area (BCA) includes U.S., Canada, Mexico, and Caribbean (excluding Cuba) Coverage available for spouses/domestic partners and dependents up to age 26.
When is your next medical emergency planned? Are you prepared?
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Platinum Membership Benefits Emergency Air Medical Transportation
Emergency Ground Transportation
Non-Emergent Air Transportation
Should a member suffer serious life or limb threatening emergency that requires immediate transport by fixed wing or helicopter air ambulance of that member to the nearest most appropriate medical facility capable of providing required emergency medical treatments, also referred to as “golden hour transports”, MASA MTS will cover the out-ofpocket expenses resulting from that transport. (U.S. and Canada Only) Should a member suffer a life or limb emergency requiring emergent ground transport from the site of serious illness or injury, or from a transferring medical facility that is unable to provide services required, to the nearest most appropriate medical facility capable of attending to the member’s medical needs MASA MTS will cover the out-of-pocket expenses resulting from that transport. (U.S. and Canada Only) Should a member suffer a serious illness or injury resulting in hospitalization and if the member is in need of specialized treatment not available locally but such transportation is not immediately needed for life or limb saving treatment and such transportation can be arranged by MASA, then MASA MTS will coordinate transport to the nearest appropriate medical facility capable of providing such specialized treatment. (Worldwide Coverage)
Organ Retrieval**
MASA MTS will provide air transportation of an organ to be used in an organ transplant. (U.S. Only)
Organ Recipient Transportation**
MASA MTS will fly a member to the commercial airport nearest the medical facility where an organ transplant is scheduled to happen. (U.S. Only)
Recuperation / Repatriation
If a member is hospitalized while away from home, MASA MTS will fly them back to a hospital closer to home to recuperate in familiar surroundings. (Worldwide Coverage)
Return Transportation
MASA MTS will arrange transport on a commercial carrier to a commercial airport closest to member’s residence after being discharged from a hospitalization of at least 24 hours. (Worldwide Coverage)
Escort Transportation
If a member requires emergency air transport, MASA MTS will fly the member's spouse, family member or friend to accompany them in the air. (Worldwide Coverage)
If a member is hospitalized while away from his/her home for more than 7 days, the member may select a family member to visit them during confinement. MASA MTS will provide Visitor Transport round trip, common carrier air transportation for the person selected. (Basic Coverage Area Only*) When minor children or grandchildren are left unattended as a result of a member using MASA MTS air ambulance service, MASA MTS will provide one-way common carrier air Minor Children / Grandchildren Return transport for return of the children to the commercial airport nearest the place of residence of the children. (Basic Coverage Only*) MASA MTS will return vehicles such as cars, vans, RVs or trucks owned or rented by the member when illness, injury or death requires use of the air ambulance services provided Vehicle Return by MASA MTS. The vehicle will be carried to the member's place of residence or rental vehicles will be returned to the nearest rental company office or agent. (Basic Coverage Area Only*) In the event a member dies while away from his/her place of residence, MASA Assist will Mortal Remains return his/her remains to the commercial airport nearest his/her residence. (Worldwide Transport Coverage) MASA MTS will return the Member’s dog, cat or smaller animal, should the Member be Pet Return flown to a hospital near their residence on an air ambulance arranged by the MASA MTS. (Basic Coverage Area Only*)
*Basic Coverage Area includes U.S., Canada, Mexico, and Caribbean (excluding Cuba). **One (1) year waiting period if pre-existing condition requiring transplant. - There is a 90 day waiting period on pre-existing conditions. This clause is WAIVED for emergent ground and air transports - Dependents are covered up until age 26.
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NOTES
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WWW.MYBENEFITSHUB.COM/FORTWORTHISD 96