LIFE SCHOOL OF DALLAS
BENEFIT GUIDE EFFECTIVE: 09/01/2021 - 8/31/2022
WWW.MYBENEFITSHUB.COM/LIFESCHOOLOFDALLAS 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) Cigna Medical EECU Health Savings Account (HSA) NBS Flexible Spending Account (FSA) The Hartford Hospital Indemnity Plan Lincoln Financial Group Dental Superior Vision UNUM Short Term Disability UNUM Long Term Disability OneAmerica Life and AD&D 5Star Family Protection Plan VOYA Accident UNUM Critical Illness MASA Emergency Transport Aura Identity Guard Identity Theft NBS 403(b) Retirement Planning 2
3 4-5 6-11 6 7 8 9 10
FLIP TO... PG. 4
HOW TO ENROLL
PG. 6
BENEFIT UPDATES
PG. 12
YOUR BENEFITS
11 12-63 64-65 66-71 72-75 76-81 82-83 84-87 88-91 92-97 98-101 102-105 106-109 110-111 112-113 114-115
Benefit Contact Information BENEFIT ADMINISTRATOR
VISION
DENTAL
Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/ lifeschoolofdallas
Superior Vision Group #037494 (800) 507-3800 Superior National Network www.superiorvision.com
Lincoln Financial Group (800) 423-2765 Dental Low Plan: 0001D040928 Dental High Plan: 0001D040929 Dental HMO: 0001D040930 https://www.lfg.com/
LIFE SCHOOL OF DALLAS BENEFITS
DISABILITY
CRITICAL ILLNESS
Mayda Falcon Central Office (469)850-5433 Mayda.Falcon@lifeschools.net
UNUM (866) 679-3054 STD Group #419941 LTD Group #419942 www.unum.com
The Hartford Group #: 884986 (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com
MEDICAL
HEALTH SAVINGS ACCOUNT
FLEXIBLE SPENDING ACCOUNT
Cigna Medical Group #3344507 (800) 244-6224 www.mycigna.com
EECU (817) 882-0800 www.eecu.org
National Benefit Services (800) 274-0503 www.nbsbenefits.com
HOSPITAL INDEMNITY PLAN
FAMILY PROTECTION PLAN
LIFE AND AD&D
The Hartford Group #:884986 (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com
5 Star Life Insurance Company (866) 863-9753 www.5starlifeinsurance.com
OneAmerica Financial Partners, Inc. (800) 537-6442 Base Life Group #00617146 Term Life Group #00617146 www.oneamerica.com
ACCIDENT
EMERGENCY MEDICAL TRANSPORT
IDENTITY THEFT PROTECTION
VOYA Financial Group #0070618-3 (800) 955-7736 www.voya.com
MASA Group # MKLIFE (800) 423-3226 www.masamts.com
Aura Identity Guard (855) 443-7748 www.identityguard.com
403(B) RETIREMENT PLANNING NBS Retirement Service Center 800 274 0503 ext 2,5 nbsbenefits.com/403b 3
MOBILE APP DOWNLOAD Enrollment made simple through the new FBS Benefits App! Text “FBS LSDAL” to (800) 583-6908
and get access to everything you need to complete your benefits
“FBS LSDAL” to
(800) 583-6908
enrollment: •
Enrollment Resources
•
Online Support
•
Interactive Tools
•
And more!
App Group #: FBSLSDAL
4
Text
OR SCAN
How to Log In
1 BENEFIT INFO
INTERACTIVE TOOLS
2 3
www.mybenefitshub.com/ lifeschoolofdallas
CLICK LOGIN
ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below:
Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.
ONLINE SUPPORT
If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.
Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.
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Annual Benefit Enrollment
SUMMARY PAGES
Benefit Updates - What’s New: MEDICAL PLAN CHANGE TO CIGNA EFFECTIVE 9/1/2021! LIFE SCHOOL EMPLOYER PAID BENEFITS Your new Medical Plan carrier effective 9/1/2021 is Cigna • Basic Life - Life School offers $20,000 life insurance with Medical. The plans offer deductible amounts of $1000, $2000, AD&D coverage to all full-time eligible employees at no cost and $3000. Currently enrolled employees under BCBS Medical to you. Remember to add/update your beneficiary during will be rolled into the deductible that is closest to their current open enrollment. plan. All plans will offer In-Network and Out-of-Network services, • Employee Assistance Plan (EAP) - includes 3 face to face but deductible amounts and co-pays will be different based on sessions. the network and plan you choose. Please reach out to your providers to see if they are contracted with CIGNA under the • Long Term Disability - Life School provides Long Term Open Access Plus Network or call CIGNA at (800) 244-6224 for Disability protection on the 91st day to their employees at more information. no cost! This valuable benefit provides 60% of your monthly There are $0 co-pays for all PCP visits and Telehealth visits earnings up to a maximum of $9,500 monthly. through MDLIVE for the Core and Buy Up plans. Prescription Drugs benefits on the Core and Buy Up plans offer a co-pay with • Dental Plans - Don't forget Life School offers a dental contribution to help offset your dental premium. Employer a $0 deductible. The High Deductible plan does not offer a co-pay contribution amounts are listed in the rates section of the for prescription drugs or doctors’ visits because the cost will be dental PPO and DHMO plan summaries. applied to your deductible. NEW IDENTITY THEFT PLAN FOR 2021 New Benefit! Aura Identity Guard! This plan offers cyber wellness by protecting you against identity thief, device security, and data privacy breaches 24/7. Mobile App available to review your account at anytime should you receive an alert.
• •
• •
Login and complete your supplemental benefit enrollment from 08/04/2021 - 08/16/2021 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8 AM—7 PM. Bilingual assistance is available. Update your profile information: home address, phone numbers, email. IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.
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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): Marital Status
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of your qualifying event and meet with your Benefit 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 A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
A change in number of dependents includes the following: birth, adoption and placement for Change in Number of adoption. You can add existing dependents not previously enrolled whenever a dependent Tax Dependents gains eligibility as a result of a valid change in status event. Change in Status of Change in employment status of the employee, or a spouse or dependent of the employee, Employment Affecting that affects the individual's eligibility under an employer's plan includes commencement or Coverage Eligibility termination of employment. Gain/Loss of Dependents' Eligibility Status
Judgment/Decree/ Order
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent 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 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
Eligibility for Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Government Programs
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SUMMARY PAGES
Annual Enrollment During your annual enrollment period, you have the opportunity
Where can I find forms?
to review, change or continue benefit elections each year.
For benefit summaries and claim forms, go to your school
Changes are not permitted during the plan year (outside of
district’s benefit website: www.mybenefitshub.com/
annual enrollment) unless a Section 125 qualifying event occurs.
lifeschoolofdallas. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you
•
Changes, additions or drops may be made only during the
need under the Benefits and Forms section.
annual enrollment period without a qualifying event. How can I find a Network Provider?
• Employees must review their personal information and verify that dependents they wish to provide coverage for are
district’s website: www.mybenefitshub.com/
included in the dependent profile. Additionally, you must
lifeschoolofdallas. Click on the benefit plan you need
notify your employer of any discrepancy in personal and/or
information on (i.e., Dental) and you can find provider search
benefit information.
•
For benefit summaries and claim forms, go to your school
Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and
New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this time frame will result in the forfeiture of coverage.
verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits department or you can call Financial Benefit Services at 866-914-5202 for assistance. 8
SUMMARY PAGES
Employee Eligibility Requirements
Dependent Eligibility Requirements
Supplemental Benefits: Eligible employees must work 32 or more
Dependent Eligibility: You can cover eligible dependent
regularly scheduled hours each work week.
children under a benefit that offers dependent coverage,
Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if
provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.
your 2021 benefits become effective on September 1, 2021, you must be actively-at-work on September 1, 2021 to be eligible for
your new benefits. PLAN
CARRIER
MAXIMUM AGE
Medical
Cigna Medical
26
Dental
Lincoln Financial Group
26
Critical Illness
The Hartford
26
Accident
VOYA
26
Vision
Superior Vision
26
Flexible Spending Account (FSA)
NBS
IRS Tax Dependent
Health Savings Account
EECU
IRS Tax Dependent
Life/AD&D
OneAmerica
26
Emergency Medical Transport
MASA
26
Hospital Indemnity Plan
The Hartford
26
Identity Theft
Aura Identity Guard
26
Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents. Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility. FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance. Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility. Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage. 9
SUMMARY PAGES
Helpful Definitions Actively at Work
In-Network
You are performing your regular occupation for the employer
Doctors, hospitals, optometrists, dentists and other providers
on a full-time basis, either at one of the employer’s usual
who have contracted with the plan as a network provider.
places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1 please notify your benefits administrator.
Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.
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.
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
Calendar Year
orders to take drugs, or received medical care or services
January 1st through December 31st
(including diagnostic and/or consultation services).
Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed
coverage is only available during the initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.
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SUMMARY PAGES
HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care tax-free.
Employer Eligibility
A qualified high deductible health plan.
All employers
Contribution Source Account Owner Underlying Insurance Requirement
Employee and/or employer Individual
Employee and/or employer Employer
High deductible health plan
None
Description
Minimum Deductible Maximum Contribution
$1,400 single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021)
N/A $2,750
Permissible Use Of Funds
If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).
Not permitted
Year-to-year rollover of account balance?
Yes, will roll over to use for subsequent year’s health coverage.
No. Access to some funds may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
FLIP TO FOR HSA INFORMATION
PG. 64
FLIP TO FOR FSA INFORMATION
PG. 66 11
CIGNA MEDICAL
Medical
YOUR BENEFITS PACKAGE
About this Benefit 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.
This12is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Medical Plan Rates
2021-22 Cigna Medical Premiums Buy Up Plan (Open Access 1000)
Monthly
Bi-Weekly
Bi-Weekly
Total Premium
Paid by Life School
Paid by Employee
Paid by Life School
Paid by Employee
$687.81
$525.00
$162.81
$262.50
$81.41
Emp + Spouse
$1,829.23
$525.00
$1,304.23
$262.50
$652.12
Emp + Child(ren)
$1,207.26
$525.00
$682.26
$262.50
$341.13
Emp + Family
$2,430.71
$525.00
$1,905.71
$262.50
$952.86
Monthly
Bi-Weekly
Bi-Weekly
Employee
Core Plan (Open Access 2000) Total Premium
Paid by Life School
Paid by Employee
Paid by Life School
Paid by Employee
$654.38
$525.00
$129.38
$262.50
$64.69
Emp + Spouse
$1,739.98
$525.00
$1,214.98
$262.50
$607.49
Emp + Child(ren)
$1,148.42
$525.00
$623.42
Emp + Family
$2,312.03
$525.00
$1,787.03
$262.50
$893.52
Monthly
Bi-Weekly
Bi-Weekly
Employee
High Deductible Plan (Open Access HDHP 3000)
$262.50
$311.71
Total Premium
Paid by Life School
Paid by Employee
Paid by Life School
Paid by Employee
$607.78
$525.00
$82.78
$262.50
$41.39
Emp + Spouse
$1,614.61
$525.00
$1,089.61
$262.50
$544.81
Emp + Child(ren)
$1,065.97
$525.00
$540.97
$262.50
$270.49
Emp + Family
$2,145.16
$525.00
$1,620.16
$262.50
$810.08
Employee
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2021-2022 CIGNA Medical Plans Effective Date: 09/01/2020
LifeSchool of Dallas
PLANS
$3000 HD Plan
$2000 Core Plan - NEW
$1000 Buy Up Plan - NEW
Network Access
Open Access Network
Open Access Network
Open Access Network
EE Only EE + Sp EE + Ch EE + Fm
EE Only EE + Sp EE + Ch EE + Fm
EE Only EE + Sp EE + Ch EE + Fm
Employee Monthly Premium (After Employer Contribution)
$82.78 $1,089.61 $540.97 $1,620.16
$129.38 $1,214.98 $623.42 $1,787.03
$162.81 $1,304.23 $682.26 $1,905.71
Deductibles (Individual / Family)
$3,000 / $6,000
$2,000 / $4,000
$1,000 / $2,000
Coinsurance
The Plan pays 100% after deductible
The Plan pays 80% You pay 20% after deductible
The Plan pays 80% You pay 20% after deductible
Out-of-Pocket Maximum (Individual / Family) includes Copays & Deductible
$3,000 / $6,000 INNET $12,000 / $24,000 OON
$4,500 / $9,000 INNET $9,000 / $18,000 OON
$3,000 / $6,000 INNET $6,000 / $12,000 OON
Primary Doctor Office Visit
Subject to deductible
$0 copay
$0 copay
Specialist Office Visit
Subject to deductible
$50 copay
$40 copay
Urgent Care
Subject to deductible
$75 copay
$75 copay
Inpatient Hospital Outpatient Hospital Emergency Room
Subject to deductible
Prescription Drugs Generic (30day/90day) Brand Non-Preferred Brand Pharmacy Mail Order Program Available
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$20/$50 $40/$100 $75/$175
Subject to deductible
•
Plan Features
80% of allowable amount 80% of allowable amount after Deductible after Deductible ($250 ER copay) ($250 ER copay)
• •
Preventive Care 100% Eligible for HSA Account 100% covered after deductible
• •
Preventive Care 100% MDLive $0 copay
$20/$50 $40/$100 $75/$175
• •
Preventive Care 100% MDLive $0 copay
BENEFIT SUMMARY
Plan Highlights
In-Network
Out-of-Network
Proclaim - 14449605 - V 22 - 08/04/21 11:05 AM ET
09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 1 of 14
©Cigna 2021
Unlimited Unlimited Your Plan’s Deductibles, Out-of-Pockets and benefit level limits accumulate on a contract year basis unless otherwise stated. In addition, all plan maximums and servicePlan Year Accumulation specific maximums (dollar and occurrence) cross-accumulate between In- and Out-ofNetwork unless otherwise noted. Plan Coinsurance Plan pays 100% Plan pays 70% Maximum Reimbursable Charge Not Applicable 110% Individual - Employee Only: $3,000 Individual - Employee Only: $6,000 Plan Deductible Individual - within a Family: $3,000 Individual - within a Family: $6,000 Family Maximum: $6,000 Family Maximum: $12,000 Only the amount you pay for in-network covered expenses counts towards your in-network deductible. Only the amount you pay for out-of-network covered expenses counts towards your out-of-network deductible. Plan deductible always applies before any benefit copay/deductible or coinsurance. Plan deductible does not apply to in-network preventive services. Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance. This plan includes a combined Medical/Pharmacy plan deductible. Note: Services where plan deductible applies are noted with a caret (^).
Lifetime Maximum
Cigna Health and Life Insurance Co. For - Lifeschool of Dallas Open Access Plus Plan HDHPQ $3,000 Effective - 09/01/2021 Selection of a Primary Care Provider - your plan may require or allow the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. If your plan requires designation of a primary care provider, Cigna may designate one for you until you make this designation. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider. Direct Access to Obstetricians and Gynecologists - You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. A notice for Texas residents: This plan does not include an optional rider to cover elective abortions.
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Plan Highlights
In-Network
Out-of-Network
In-Network
Out-of-Network
Proclaim - 14449605 - V 22 - 08/04/21 11:05 AM ET
09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000
Preventive Care
Plan pays 100%
2 of 14
©Cigna 2021
PCP: Plan pays 70% ^ Specialist: Plan pays 70% ^ Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit when billed as part of office visit. Annual Limit: Unlimited
Preventive Care
Primary Care Physician (PCP) Services/Office Visit Plan pays 100% ^ Plan pays 70% ^ Specialty Care Physician Services/Office Visit Plan pays 100% ^ Plan pays 70% ^ NOTE: Obstetrician and Gynecologist (OB/GYN) visits are subject to either the PCP or Specialist cost share depending on how the provider contracts with Cigna (i.e. as PCP or as Specialist). Covered same as Physician Services Covered same as Physician Services Surgery Performed in Physician's Office Office Visit Office Visit Allergy Treatment/Injections and Allergy Serum Covered same as Physician Services Covered same as Physician Services Allergy serum dispensed by the physician in the office Office Visit Office Visit Cigna Telehealth Connection Services (Virtual Care) Plan pays 100% ^ Not Covered Includes charges for the delivery of medical and health-related services and consultations by dedicated virtual providers as medically appropriate through audio, video, and secure internet-based technologies. Virtual Wellness Screenings are available for individuals 18 and older and are covered same as Preventive Care (see Preventive Care Section). Telehealth services rendered by providers that are not contracted medical telehealth providers (as described on myCigna.com) are covered at the same benefit level as the same services would be if rendered in-person.
Physician Services - Office Visits
Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles.
Benefit
Individual - Employee Only: $3,000 Individual - Employee Only: $12,000 Plan Out-of-Pocket Maximum Individual - within a Family: $3,000 Individual - within a Family: $12,000 Family Maximum: $6,000 Family Maximum: $24,000 Only the amount you pay for in-network covered expenses counts toward your in-network out-of-pocket maximum. Only the amount you pay for out-of-network covered expenses counts toward your out-of-network out-of-pocket maximum. Plan deductible contributes towards your out-of-pocket maximum. All benefit copays/deductibles contribute towards your out-of-pocket maximum. Covered expenses that count towards your out-of-pocket maximum include customer paid coinsurance and charges for Mental Health and Substance Use Disorder. Out-of-network non-compliance penalties or charges in excess of Maximum Reimbursable Charge do not contribute towards the out-of-pocket maximum. After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member's covered expenses. This plan includes a combined Medical/Pharmacy out-of-pocket maximum.
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Benefit
In-Network
Out-of-Network
Plan pays 70% ^ Plan pays 70% ^
Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities Annual Limit: 30 days
Inpatient Services at Other Health Care Facilities
Proclaim - 14449605 - V 22 - 08/04/21 11:05 AM ET
09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 3 of 14
Plan pays 100% ^
Plan pays 70% ^
Emergency Room Plan pays 100% ^ Plan pays 100% ^ Includes Professional, X-ray and/or Lab services performed at the Emergency Room and billed by the facility as part of the ER visit. Urgent Care Facility Includes Professional, X-ray and/or Lab services performed at the Plan pays 100% ^ Plan pays 100% ^ Urgent Care Facility and billed by the facility as part of the urgent care visit. Ambulance Plan pays 100% ^ Plan pays 100% ^ Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered.
Emergency Services
Outpatient Facility Services Plan pays 100% ^ Outpatient Professional Services Plan pays 100% ^ For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists
Outpatient
Inpatient Hospital Facility Services Plan pays 100% ^ Plan pays 70% ^ Note: Includes all Lab and Radiology services, including Advanced Radiological Imaging as well as Medical Specialty Drugs Inpatient Hospital Physician's Visit/Consultation Plan pays 100% ^ Plan pays 70% ^ Inpatient Professional Services Plan pays 100% ^ Plan pays 70% ^ For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists
Inpatient
©Cigna 2021
PCP: Plan pays 70% ^ Specialist: Plan pays 70% ^ Covered same as other x-ray and lab services, based on Place of Service
Coverage includes the associated Preventive Outpatient Professional Services. Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on Place of Service.
Plan pays 100%
Mammogram, PAP, and PSA Tests
Plan pays 100%
Ages 6 and older
Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles. Immunizations Plan pays 100% Plan pays 100% Birth through age 5
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Benefit
In-Network
Out-of-Network
Laboratory Services
Covered same as Physician Services Office Visit
Covered same as Physician Services Office Visit
Plan pays 70% ^ Plan pays 70% ^
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000
Services Provided by a Mental Health Professional
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Covered under Mental Health benefit
©Cigna 2021
Covered under Mental Health benefit
Bereavement Counseling (for services not provided as part of a hospice program)
Inpatient Facilities Plan pays 100% ^ Outpatient Services Plan pays 100% ^ Note: Includes Bereavement counseling provided as part of a hospice program.
Hospice
Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Covered same as Physician Services Covered same as Physician Services Cardiac Rehabilitation Services Office Visit Office Visit Annual Limit: Cardiac Rehabilitation - 36 days
Annual Limits: All Therapies Combined - Includes Chiropractic Care, Cognitive Therapy, Occupational Therapy, Physical Therapy, Pulmonary Rehabilitation, and Speech Therapy - 35 days Limits are not applicable to mental health conditions for Physical, Speech and Occupational Therapies.
Outpatient Therapy and Chiropractic Services
Outpatient Therapy Services
Physician’s Services/Office Visit
Plan pays 70% ^ Covered same as Physician Services Office Visit
Plan pays 100% ^ Covered same as Physician Services Office Visit
Outpatient Facility
Covered same as Physician Services Office Visit Plan pays 70% ^
Includes MRI, MRA, CAT Scan, PET Scan, etc.
Covered same as Physician Services Office Visit Plan pays 100% ^
Covered same as Physician Services Office Visit Plan pays 70% ^ Plan pays 70% ^
Advanced Radiological Imaging (ARI)
Outpatient Facility
Physician’s Services/Office Visit
Radiology Services
Independent Lab Outpatient Facility
Physician’s Services/Office Visit
Covered same as Physician Services Office Visit Plan pays 100% ^ Plan pays 100% ^
Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles.
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Benefit
In-Network
Out-of-Network
Plan pays 100% ^ Plan pays 100% ^
Physician's Office
Home
Plan pays 70% ^
Plan pays 70% ^
Plan pays 70% ^
Plan pays 100%
Coverage varies based on Place of Service
Covered same as Physician Services Office Visit Covered same as plan’s Inpatient Hospital benefit
Covered same as Physician Services Office Visit Covered same as plan’s Inpatient Hospital benefit Coverage varies based on Place of Service
Plan pays 70% ^
Covered same as Physician Services Office Visit
Plan pays 100% ^
Covered same as Physician Services Office Visit
Women’s Services
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 5 of 14
©Cigna 2021
Coverage varies based on Place of Service Includes contraceptive devices as ordered or prescribed by a physician and surgical sterilization services, such as tubal ligation (excludes reversals) Coverage varies based on Place of Coverage varies based on Place of Men’s Services Service Service Includes surgical sterilization services, such as vasectomy (excludes reversals)
Family Planning
Note: Non-elective procedures only
Abortion Services
Abortion
All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges (Global Maternity Fee) Office Visits in Addition to Global Maternity Fee (Performed by OB/GYN or Specialist) Delivery - Facility (Inpatient Hospital, Birthing Center)
Initial Visit to Confirm Pregnancy
Maternity
Note: This benefit only applies to the cost of the Infusion Therapy drugs administered. This benefit does not cover the related Facility, Office Visit or Professional charges.
Plan pays 100% ^
Outpatient Facility
Medical Specialty Drugs
Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles.
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Benefit
In-Network
Out-of-Network
Infertility
Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles.
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 6 of 14
Travel Maximum - After the plan deductible is met, $10,000 maximum per Transplant per Lifetime Durable Medical Equipment Plan pays 100% ^ Annual Limit: Unlimited Breast Feeding Equipment and Supplies Limited to the rental of one breast pump per birth as ordered or Plan pays 100% prescribed by a physician Includes related supplies External Prosthetic Appliances (EPA) Plan pays 100% ^ Annual Limit: Unlimited
Non-LifeSOURCE Facility
Covered same as plan’s Inpatient Professional benefit
Home Health Care Plan pays 100% ^ Annual Limit: 60 days (The limit is not applicable to mental health and substance use disorder conditions.) 16 hour maximum per day Note: Includes outpatient private duty nursing when approved as medically necessary Organ Transplants Inpatient Hospital Facility Services LifeSOURCE Facility Plan pays 100% ^ Covered same as plan’s Inpatient Hospital Non-LifeSOURCE Facility benefit Inpatient Professional Services LifeSOURCE Facility Plan pays 100% ^
Other Health Care Facilities/Services
Plan pays 70% ^
Plan pays 70% ^
Plan pays 70% ^
Bone Marrow - $130,000 Heart - $150,000 Heart/Lung - $185,000 Kidney - $80,000 Kidney/Pancreas - $80,000 Liver - $230,000 Lung - $185,000 Pancreas - $50,000
©Cigna 2021
Not Applicable Covered same as plan's Inpatient Professional benefit up to the following transplant maximums:
Not Applicable Covered same as plan’s Inpatient Hospital benefit
Plan pays 70% ^
Infertility Treatment Note: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness.
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Benefit
In-Network
Out-of-Network
Plan pays 100% ^ Plan pays 100% ^ Plan pays 100% ^ Plan pays 100% ^ Plan pays 100% ^ Plan pays 100% ^
Plan pays 70% ^ Plan pays 70% ^ Plan pays 70% ^ Plan pays 70% ^ Plan pays 70% ^ Plan pays 70% ^
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 7 of 14
Cigna Total Behavioral Health - Inpatient and Outpatient Management Inpatient utilization review and case management Outpatient utilization review and case management Partial Hospitalization Intensive outpatient programs Changing Lives by Integrating Mind and Body Program Lifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management. Narcotic Therapy Management Complex Psychiatric Case Management
©Cigna 2021
Notes: Inpatient includes Acute Inpatient and Residential Treatment. Outpatient - Physician's Office - may include Individual, family and group therapy, psychotherapy, medication management, etc. Outpatient - All Other Services - may include Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy), etc. Services are paid at 100% after you reach your out-of-pocket maximum. Mental Health/Substance Use Disorder Utilization Review, Case Management and Programs
Inpatient Mental Health Outpatient Mental Health – Physician’s Office Outpatient Mental Health – All Other Services Inpatient Substance Use Disorder Outpatient Substance Use Disorder – Physician’s Office Outpatient Substance Use Disorder – All Other Services Annual Limits: Unlimited maximum
Mental Health and Substance Use Disorder
Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles. Temporomandibular Joint Disorder (TMJ) Coverage varies based on Place of Coverage varies based on Place of Service Service Unlimited lifetime maximum Note: Provided on a limited, case-by-case basis. Excludes appliances and orthodontic treatment. Routine Foot Care Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Hearing Aids Plan pays 100% ^ Plan pays 70% ^ Maximum of 2 devices (one per ear) per 36 months Includes testing and fitting of hearing aid devices at Physician Office Visit cost share Coverage through age 18
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Retail and Home Delivery (per 90-day supply): Generic: You pay 0% ^ Preferred Brand: You pay 10% ^ Non-Preferred Brand: You pay 20% ^
Retail (per 30-day supply): Generic: You pay 0% ^ Preferred Brand: You pay 10% ^ Non-Preferred Brand: You pay 20% ^
In-Network
Home Delivery: Same as Retail Out-of-Network
Retail: You pay 50% ^ Your plan pays 50% ^
Out-of-Network
Retail drugs for a 30 day supply may be obtained In-Network at a wide range of pharmacies across the nation although prescriptions for a 90 day supply (such as maintenance drugs) will be available at select network pharmacies. Cigna 90 Now Program: You can choose to fill your medications in a 30- or 90-day supply. If you choose to fill a 30-day prescription, it can be filled at any network retail pharmacy or network home delivery pharmacy. If you choose to fill a 90-day prescription, it must be filled at a 90-day network retail pharmacy or network home delivery pharmacy to be covered by the plan. Specialty medications are used to treat an underlying disease which is considered to be rare and chronic including, but not limited to, multiple sclerosis, hepatitis C or rheumatoid arthritis. Specialty Drugs may include high cost medications as well as medications that may require special handling and close supervision when being administered. When patient requests brand drug, patient pays the brand cost share plus the cost difference between the brand and generic drugs up to the cost of the brand drug (unless the physician indicates "Dispense As Written" DAW). Your pharmacy benefits share an annual deductible and out-of-pocket maximum with the medical/behavioral benefits. The applicable cost share for covered drugs applies after the combined deductible has been met. Specialty Drugs provided at Home Delivery at the Retail (per 30-day supply) cost share.
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 8 of 14
©Cigna 2021
Prescription Drug List: Your Cigna Standard Prescription Drug List includes a full range of drugs including all those required under applicable health care laws. To check which drugs are included in your plan, please log on to myCigna.com. Some highlights: Coverage includes Self Administered injectables and optional injectable drugs – but excludes infertility drugs. Contraceptive devices and drugs are covered with federally required products covered at 100%. Insulin, glucose test strips, lancets, insulin needles & syringes, insulin pens and cartridges are covered.
Drugs Covered
Cigna Pharmacy Cost Share Retail – up to 90-day supply (except Specialty up to 30-day supply) Home Delivery – up to 90-day supply (except Specialty up to 30-day supply)
Pharmacy Cost Share and Supply
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Health Assessments Health and Wellness Coaching Gaps in Care Coaching Treatment Decision Support Educate and Refer Healthy Pregnancies/Healthy Babies Care Management outreach Maternity Case Management Neo-natal Case Management
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 9 of 14
$150 (1st trimester) / $75 (2nd trimester) - Option 3
Included
©Cigna 2021
Case Management Coordinated by Cigna HealthCare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective care while maximizing the patient's quality of life. Comprehensive Oncology Program Care Management outreach Included Case Management Health Advisor - A Support for healthy and at-risk individuals to help them stay healthy
Additional Information
Pharmacy Clinical Management: Essential Your plan features drug management programs and edits to ensure safe prescribing, and access to medications proven to be the most reliable and cost effective for the medical condition, including: Prior authorization requirements Step Therapy on select classes of medications and drugs new to the market Quantity limits, including maximum daily dose edits, quantity over time edits, duration of therapy edits, and dose optimization edits Age edits, and refill-too-soon edits Plan exclusion edits Current users of Step Therapy medications will be allowed one 30-day fill during the first three months of coverage before Step Therapy program applies. Your plan includes Specialty Drug Management features, such as prior authorization and quantity limits, to ensure the safe prescribing and access to specialty medications. For customers with complex conditions taking a specialty medication, we will offer Accredo Therapeutic Resource Centers (TRCs) to provide specialty medication and condition counseling. For customers taking a specialty medication not dispensed by Accredo, Cigna experts will offer this important specialty medication and condition counseling.
Pharmacy Program Information
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Additional Information
Maximum Reimbursable Charge The allowable covered expense for non-network services is based on the lesser of the health care professional's normal charge for a similar service or a percentage of a fee schedule (110%) developed by Cigna that is based on a methodology similar to one used by Medicare to determine the allowable fee for the same or similar service in a geographic area. In some cases, the Medicare based fee schedule will not be used and the maximum reimbursable charge for covered services is based on the lesser of the health care professional's normal charge for a similar service or a percentile (80th) of charges made by health care professionals of such service or supply in the geographic area where it is received. If sufficient charge data is unavailable in the database for that geographic area to determine the Maximum Reimbursable Charge, then data in the database for similar services may be used. Out-of-network services are subject to a Contract Year deductible and maximum reimbursable charge limitations.
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 10 of 14
©Cigna 2021
When a person is eligible for Medicare A and B as described above, this plan will pay as the Secondary Plan to Medicare Part A and B regardless if the person is actually enrolled in Medicare Part A and/or Part B and regardless if the person seeks care at a Medicare Provider or not for Medicare covered services. Multiple Surgical Reduction Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery. One Guide Available by phone or through myCigna mobile application. One Guide helps you navigate the health care system and make the most of your health benefits and programs.
The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is also responsible for all charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card. Medicare Coordination In accordance with the Social Security Act of 1965, this plan will pay as the Secondary plan to Medicare Part A and B as follows: (a) a former Employee such as a retiree, a former Disabled Employee, a former Employee's Dependent, or an Employee's Domestic Partner who is also eligible for Medicare and whose insurance is continued for any reason as provided in this plan (including COBRA continuation); (b) an Employee, a former Employee, an Employee’s Dependent, or former Employee’s Dependent, who is eligible for Medicare due to End Stage Renal Disease after that person has been eligible for Medicare for 30 months.
Out-of-Network Emergency Services Charges 1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-participating (Out-of-Network) provider. 2. The allowable amount used to determine the Plan's benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-ofNetwork provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or if no amount is agreed to, the greater of the following: (i) the median amount negotiated with In-Network providers for the Emergency Service, excluding any In-Network copay or coinsurance; (ii) the Maximum Reimbursable Charge; or (iii) the amount payable under the Medicare program, not to exceed the provider's billed charges.
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Additional Information
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 11 of 14
©Cigna 2021
Pre-Certification - Continued Stay Review - Preferred Care Management Inpatient - required for all inpatient admissions In-Network: Coordinated by your physician Out-of-Network: Customer is responsible for contacting Cigna Healthcare. Subject to penalty/reduction or denial for non-compliance. 50% penalty applied to hospital inpatient charges for failure to contact Cigna Healthcare to precertify admission. Benefits are denied for any admission reviewed by Cigna Healthcare and not certified. Benefits are denied for any additional days not certified by Cigna Healthcare. Pre-Certification - Preferred Care Management Outpatient Prior Authorization - required for selected outpatient procedures and diagnostic testing In-Network: Coordinated by your physician Out-of-Network: Customer is responsible for contacting Cigna Healthcare. Subject to penalty/reduction or denial for non-compliance. 50% penalty applied to outpatient procedures/diagnostic testing charges for failure to contact Cigna Healthcare and to precertify admission. Benefits are denied for any outpatient procedures/diagnostic testing reviewed by Cigna Healthcare and not certified. Pre-Existing Condition Limitation (PCL) does not apply. Holistic health support for the following chronic health conditions: Heart Disease Coronary Artery Disease Angina Your Health First - 200 Congestive Heart Failure Individuals with one or more of the chronic conditions, identified on the right, may be eligible to receive the following type of support: Acute Myocardial Infarction Peripheral Arterial Disease Condition Management Asthma Medication adherence Chronic Obstructive Pulmonary Disease (Emphysema and Chronic Risk factor management Bronchitis) Lifestyle issues Diabetes Type 1 Health & Wellness issues Diabetes Type 2 Pre/post-admission Metabolic Syndrome/Weight Complications Treatment decision support Osteoarthritis Gaps in care Low Back Pain Anxiety Bipolar Disorder Depression
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Coinsurance - After you've reached your deductible, you and your plan share some of your medical costs. The portion of covered expenses you are responsible for is called Coinsurance. Copay - A flat fee you pay for certain covered services such as doctor's visits or prescriptions. Deductible - A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered services. Out-of-Pocket Maximum - Specific limits for the total amount you will pay out of your own pocket before your plan coinsurance percentage no longer applies. Once you meet these maximums, your plan then pays 100 percent of the "Maximum Reimbursable Charges" or negotiated fees for covered services. Place of Service - Your plan pays based on where you receive services. For example, for hospital stays, your coverage is paid at the inpatient level. Prescription Drug List - The list of prescription brand and generic drugs covered by your pharmacy plan. Professional Services - Services performed by Surgeons, Assistant Surgeons, Hospital Based Physicians, Radiologists, Pathologists and Anesthesiologists Transition of Care - Provides in-network health coverage to new customers when the customer's doctor is not part of the Cigna network and there are approved clinical reasons why the customer should continue to see the same doctor.
Definitions
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000 12 of 14
©Cigna 2021
What's Not Covered (not all-inclusive): Your plan provides for most medically necessary services. The complete list of exclusions is provided in your Certificate or Summary Plan Description. To the extent there may be differences, the terms of the Certificate or Summary Plan Description control. Examples of things your plan does not cover, unless required by law or covered under the pharmacy benefit, include (but aren't limited to): Care for health conditions that are required by state or local law to be treated in a public facility. Care required by state or federal law to be supplied by a public school system or school district. Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available. Treatment of an Injury or Sickness which is due to war, declared, or undeclared. Charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan. For example, if Cigna determines that a provider or Pharmacy is or has waived, reduced, or forgiven any portion of its charges and/or any portion of Copayment, Deductible, and/or Coinsurance amount(s) you are required to pay for a Covered Expense (as shown on The Schedule) without Cigna's express consent, then Cigna shall have the right to deny the payment of benefits in connection with the Covered Expense, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider or Pharmacy represents that you remain responsible for any amounts that your plan does not cover. Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a non-Participating Provider who has agreed to charge you or charged you at an In-Network benefits level or some other benefits level not otherwise applicable to the services received. Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care. For or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be: o Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed; o Not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed; o The subject of review or approval by an Institutional Review Board for the proposed use except as provided in the "Clinical Trials" sections of this plan; or
Exclusions
26
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000
13 of 14
©Cigna 2021
The subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the "Clinical Trials" sections of this plan. o In determining whether any such technologies, supplies, treatments, drug or Biologic therapies, or devices are experimental, investigational, and/or unproven, the utilization review Physician may rely on the clinical coverage policies maintained by Cigna or the Review Organization. Clinical coverage policies may incorporate, without limitation and as applicable, criteria relating to U.S. Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scientific literature or guidelines. Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem. The following services are excluded from coverage regardless of clinical indications: macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty; panniculectomy; rhinoplasty; blepharoplasty; redundant skin surgery; removal of skin tags; acupressure; craniosacral/cranial therapy; dance therapy; movement therapy; applied kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, except as may be covered under the "Reconstructive Surgery" benefit. Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. Charges made for services or supplies provided for or in connection with an accidental Injury to teeth are covered provided a continuous course of dental treatment is started within six months of an accident. For medical and surgical services, initial and repeat, intended for the treatment or control of obesity including clinically severe (morbid) obesity, including: medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a Physician or under medical supervision. Unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations. Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan. Infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage. Reversal of male or female voluntary sterilization procedures. Any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation. Non-medical counseling or ancillary services, including but not limited to Custodial Services, educational services, vocational counseling, training and, rehabilitation services, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, return to work services, work hardening programs and, driving safety courses. Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected. Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the "Home Health Services" or "Breast Reconstruction and Breast Prostheses" sections of this plan. Private Hospital rooms and/or private duty nursing except as provided under the Home Health Services provision. Personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness. Artificial aids including, but not limited to, garter belts, corsets, dentures and wigs. Aids or devices that assist with non-verbal communications, including but not limited to communication boards, pre-recorded speech devices, laptop
o
Exclusions
27
computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books. Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post cataract surgery). Routine refractions, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy. Treatment by acupuncture. All non-injectable prescription drugs unless Physician administration or oversight is required, injectable prescription drugs to the extent they do not require Physician supervision and are typically considered self-administered drugs, non-prescription drugs, and investigational and experimental drugs, except as provided in this plan. Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary. Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs. Genetic screening or pre-implantations genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease. Dental implants for any condition. Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review Physician's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement in physical condition. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks. Cosmetics, dietary supplements and health and beauty aids. All nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism. Medical treatment when payment is denied by a Primary Plan because treatment was received from a non-Participating Provider. For or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit. Charges for the delivery of medical and health-related services via telecommunications technologies, including telephone and internet unless provided as specifically described under Covered Expenses. Massage therapy. Abortions, unless a Physician certifies in writing that the pregnancy would endanger the life of the mother, or the expenses are incurred to treat medical complications due to abortion.
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09/01/2021 TX Open Access Plus HDHPQ - HDHPQ $3,000
EHB State: TX
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©Cigna 2021
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
These are only the highlights This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including benefits required by your state, see your employer's insurance certificate, service agreement or summary plan description -- the official plan documents. If there are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Exclusions
28
If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file
• Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.
Cigna:
Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Medical coverage
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 http://www.hhs.gov/ocr/office/file/index.html.
If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Cigna Nondiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422
a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:
DISCRIMINATION IS AGAINST THE LAW
896375a 05/17
© 2017 Cigna.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
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English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).
Proficiency of Language Assistance Services
Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).
Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).
Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna,
896375a 05/17
Cigna لعمالء. – برجاء االنتباه خدمات الترجمة المجانية متاحة لكمArabic او اتصل ب.الحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصية .)711 اتصل ب:TTY( 1.800.244.6224
برای. به صورت رایگان به شما ارائه میشود٬ خدمات کمک زبانی: – توجهPersian (Farsi) در غیر. لطفا ً با شمارهای که در پشت کارت شناسایی شماست تماس بگیرید٬Cigna مشتریان فعلی را711 شماره: تماس بگیرید (شماره تلفن ویژه ناشنوایان1.800.244.6224 اینصورت با شماره .)شمارهگیری کنید
Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利 用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電 話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711） まで、お電話にてご連絡ください。
Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.
позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).
Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).
Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).
French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).
French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).
Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).
Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。
Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
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BENEFIT SUMMARY
Plan Highlights
In-Network
Out-of-Network
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©Cigna 2021
Unlimited Unlimited Your Plan’s Deductibles, Out-of-Pockets and benefit level limits accumulate on a contract year basis unless otherwise stated. In addition, all plan maximums and servicePlan Year Accumulation specific maximums (dollar and occurrence) cross-accumulate between In- and Out-ofNetwork unless otherwise noted. Plan Coinsurance Plan pays 80% Plan pays 60% Maximum Reimbursable Charge Not Applicable 110% Individual: $2,000 Individual: $4,000 Plan Deductible Family: $4,000 Family: $8,000 Only the amount you pay for in-network covered expenses counts towards your in-network deductible. Only the amount you pay for out-of-network covered expenses counts towards your out-of-network deductible. Benefit copays/deductibles always apply before plan deductible and coinsurance. Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance. Note: Services where plan deductible applies are noted with a caret (^).
Lifetime Maximum
Cigna Health and Life Insurance Co. For - Lifeschool of Dallas Open Access Plus Plan OAP Core $2,000 Deductible Effective - 09/01/2021 Selection of a Primary Care Provider - your plan may require or allow the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. If your plan requires designation of a primary care provider, Cigna may designate one for you until you make this designation. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider. Direct Access to Obstetricians and Gynecologists - You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. A notice for Texas residents: This plan does not include an optional rider to cover elective abortions.
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Plan Highlights
In-Network
Out-of-Network
In-Network
Out-of-Network
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Preventive Care
Plan pays 100%
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©Cigna 2021
PCP: Plan pays 60% ^ Specialist: Plan pays 60% ^ Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit when billed as part of office visit. Annual Limit: Unlimited
Preventive Care
Primary Care Physician (PCP) Services/Office Visit Plan pays 100% Plan pays 60% ^ Specialty Care Physician Services/Office Visit $50 copay, and plan pays 100% Plan pays 60% ^ NOTE: Obstetrician and Gynecologist (OB/GYN) visits are subject to either the PCP or Specialist cost share depending on how the provider contracts with Cigna (i.e. as PCP or as Specialist). Covered same as Physician Services Covered same as Physician Services Surgery Performed in Physician's Office Office Visit Office Visit Allergy Treatment/Injections and Allergy Serum Covered same as Physician Services Covered same as Physician Services Allergy serum dispensed by the physician in the office Office Visit Office Visit Note: Office copay does not apply if only the allergy serum is provided. Cigna Telehealth Connection Services (Virtual Care) Plan pays 100% Not Covered Includes charges for the delivery of medical and health-related services and consultations by dedicated virtual providers as medically appropriate through audio, video, and secure internet-based technologies. Virtual Wellness Screenings are available for individuals 18 and older and are covered same as Preventive Care (see Preventive Care Section). Telehealth services rendered by providers that are not contracted medical telehealth providers (as described on myCigna.com) are covered at the same benefit level as the same services would be if rendered in-person.
Physician Services - Office Visits
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
Benefit
Individual: $4,500 Individual: $9,000 Plan Out-of-Pocket Maximum Family: $9,000 Family: $18,000 Only the amount you pay for in-network covered expenses counts toward your in-network out-of-pocket maximum. Only the amount you pay for out-of-network covered expenses counts toward your out-of-network out-of-pocket maximum. Plan deductible contributes towards your out-of-pocket maximum. All benefit copays/deductibles contribute towards your out-of-pocket maximum. Covered expenses that count towards your out-of-pocket maximum include customer paid coinsurance and charges for Mental Health and Substance Use Disorder. Out-of-network non-compliance penalties or charges in excess of Maximum Reimbursable Charge do not contribute towards the out-of-pocket maximum. After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member's covered expenses. This plan includes a combined Medical/Pharmacy out-of-pocket maximum.
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Benefit
In-Network
Out-of-Network
PCP: Plan pays 60% ^ Specialist: Plan pays 60% ^ Covered same as other x-ray and lab services, based on Place of Service
Plan pays 60% ^ Plan pays 60% ^
Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities Annual Limit: 60 days
Inpatient Services at Other Health Care Facilities
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Plan pays 100%
Plan pays 60% ^
©Cigna 2021
Emergency Room Includes Professional, X-ray and/or Lab services performed at the $250 copay, and plan pays 80% $250 copay, and plan pays 80% Emergency Room and billed by the facility as part of the ER visit. Per visit copay is waived if admitted. Urgent Care Facility Includes Professional, X-ray and/or Lab services performed at the $75 copay, and plan pays 100% $75 copay, and plan pays 100% Urgent Care Facility and billed by the facility as part of the urgent care visit. Ambulance Plan pays 80% ^ Plan pays 80% ^ Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered.
Emergency Services
Outpatient Facility Services Plan pays 80% ^ Outpatient Professional Services Plan pays 80% ^ For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists
Outpatient
Inpatient Hospital Facility Services Plan pays 80% ^ Plan pays 60% ^ Note: Includes all Lab and Radiology services, including Advanced Radiological Imaging as well as Medical Specialty Drugs Inpatient Hospital Physician's Visit/Consultation Plan pays 80% ^ Plan pays 60% ^ Inpatient Professional Services Plan pays 80% ^ Plan pays 60% ^ For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists
Inpatient
Coverage includes the associated Preventive Outpatient Professional Services. Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on Place of Service.
Plan pays 100%
Mammogram, PAP, and PSA Tests
Plan pays 100%
Ages 6 and older
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible. Immunizations Plan pays 100% Plan pays 100% Birth through age 5
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Benefit
In-Network
Out-of-Network
Laboratory Services
Plan pays 80% ^
Covered same as Physician Services Office Visit
Plan pays 60% ^ Plan pays 60% ^
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Services Provided by a Mental Health Professional
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©Cigna 2021
Covered under Mental Health benefit
Bereavement Counseling (for services not provided as part of a hospice program)
Inpatient Facilities Plan pays 100% Outpatient Services Plan pays 100% Note: Includes Bereavement counseling provided as part of a hospice program.
Hospice
Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Covered same as Physician Services Cardiac Rehabilitation Services Plan pays 80% ^ Office Visit Annual Limit: Cardiac Rehabilitation - 36 days
Annual Limits: All Therapies Combined - Includes Chiropractic Care, Cognitive Therapy, Occupational Therapy, Physical Therapy, Pulmonary Rehabilitation, and Speech Therapy - 35 days Limits are not applicable to mental health conditions for Physical, Speech and Occupational Therapies.
Outpatient Therapy and Chiropractic Services
Outpatient Therapy Services
Physician’s Services/Office Visit
Plan pays 60% ^ Covered same as Physician Services Office Visit
Plan pays 80% ^ Covered same as Physician Services Office Visit
Outpatient Facility
Covered same as Physician Services Office Visit Plan pays 60% ^
Includes MRI, MRA, CAT Scan, PET Scan, etc.
Covered same as Physician Services Office Visit Plan pays 100%
Covered same as Physician Services Office Visit Plan pays 60% ^ Plan pays 60% ^
Advanced Radiological Imaging (ARI)
Outpatient Facility
Physician’s Services/Office Visit
Radiology Services
Independent Lab Outpatient Facility
Physician’s Services/Office Visit
Covered same as Physician Services Office Visit Plan pays 100% Plan pays 100%
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
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Benefit
In-Network
Out-of-Network
Plan pays 80% ^ Plan pays 80% ^
Physician's Office
Home
Plan pays 60% ^
Plan pays 60% ^
Plan pays 60% ^
Plan pays 100%
Coverage varies based on Place of Service
Covered same as Physician Services Office Visit Covered same as plan’s Inpatient Hospital benefit
Covered same as Physician Services Office Visit Covered same as plan’s Inpatient Hospital benefit Coverage varies based on Place of Service
Plan pays 60% ^
Covered same as Physician Services Office Visit
Plan pays 80% ^
Covered same as Physician Services Office Visit
Women’s Services
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Coverage varies based on Place of Service Includes contraceptive devices as ordered or prescribed by a physician and surgical sterilization services, such as tubal ligation (excludes reversals) Coverage varies based on Place of Coverage varies based on Place of Men’s Services Service Service Includes surgical sterilization services, such as vasectomy (excludes reversals)
Family Planning
Note: Non-elective procedures only
Abortion Services
Abortion
All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges (Global Maternity Fee) Office Visits in Addition to Global Maternity Fee (Performed by OB/GYN or Specialist) Delivery - Facility (Inpatient Hospital, Birthing Center)
Initial Visit to Confirm Pregnancy
Maternity
Note: This benefit only applies to the cost of the Infusion Therapy drugs administered. This benefit does not cover the related Facility, Office Visit or Professional charges.
Plan pays 80% ^
Outpatient Facility
Medical Specialty Drugs
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
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Benefit
In-Network
Out-of-Network
Infertility
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
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Travel Maximum - $10,000 maximum per Transplant per Lifetime Durable Medical Equipment Annual Limit: Unlimited Breast Feeding Equipment and Supplies Limited to the rental of one breast pump per birth as ordered or prescribed by a physician Includes related supplies External Prosthetic Appliances (EPA) Annual Limit: Unlimited
Non-LifeSOURCE Facility
Plan pays 60% ^ Plan pays 60% ^
Plan pays 100% Plan pays 80% ^
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Plan pays 60% ^
Bone Marrow - $130,000 Heart - $150,000 Heart/Lung - $185,000 Kidney - $80,000 Kidney/Pancreas - $80,000 Liver - $230,000 Lung - $185,000 Pancreas - $50,000
©Cigna 2021
Not Applicable Covered same as plan's Inpatient Professional benefit up to the following transplant maximums:
Not Applicable Covered same as plan’s Inpatient Hospital benefit
Plan pays 60% ^
Plan pays 80% ^
Covered same as plan’s Inpatient Professional benefit
Home Health Care Plan pays 100% Annual Limit: 60 days (The limit is not applicable to mental health and substance use disorder conditions.) 16 hour maximum per day Note: Includes outpatient private duty nursing when approved as medically necessary Organ Transplants Inpatient Hospital Facility Services LifeSOURCE Facility Plan pays 100% Covered same as plan’s Inpatient Hospital Non-LifeSOURCE Facility benefit Inpatient Professional Services LifeSOURCE Facility Plan pays 100%
Other Health Care Facilities/Services
Infertility Treatment Note: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness.
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Benefit
In-Network
Out-of-Network
Plan pays 80% ^ Plan pays 100% Plan pays 80% ^ Plan pays 80% ^ Plan pays 100% Plan pays 80% ^
Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^
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Cigna Total Behavioral Health - Inpatient and Outpatient Management Inpatient utilization review and case management Outpatient utilization review and case management Partial Hospitalization Intensive outpatient programs Changing Lives by Integrating Mind and Body Program Lifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management. Narcotic Therapy Management Complex Psychiatric Case Management
©Cigna 2021
Notes: Inpatient includes Acute Inpatient and Residential Treatment. Outpatient - Physician's Office - may include Individual, family and group therapy, psychotherapy, medication management, etc. Outpatient - All Other Services - may include Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy), etc. Services are paid at 100% after you reach your out-of-pocket maximum. Mental Health/Substance Use Disorder Utilization Review, Case Management and Programs
Inpatient Mental Health Outpatient Mental Health – Physician’s Office Outpatient Mental Health – All Other Services Inpatient Substance Use Disorder Outpatient Substance Use Disorder – Physician’s Office Outpatient Substance Use Disorder – All Other Services Annual Limits: Unlimited maximum
Mental Health and Substance Use Disorder
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible. Temporomandibular Joint Disorder (TMJ) Coverage varies based on Place of Coverage varies based on Place of Service Service Unlimited lifetime maximum Note: Provided on a limited, case-by-case basis. Excludes appliances and orthodontic treatment. Routine Foot Care Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Hearing Aids Plan pays 80% ^ Plan pays 60% ^ Maximum of 2 devices (one per ear) per 36 months Includes testing and fitting of hearing aid devices at Physician Office Visit cost share Coverage through age 18
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Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $100 Non-Preferred Brand: You pay $175
Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70
In-Network
Home Delivery: Same as Retail Out-of-Network
Retail: You pay 30% Your plan pays 70%
Out-of-Network
Retail drugs for a 30 day supply may be obtained In-Network at a wide range of pharmacies across the nation although prescriptions for a 90 day supply (such as maintenance drugs) will be available at select network pharmacies. Cigna 90 Now Program: You can choose to fill your medications in a 30- or 90-day supply. If you choose to fill a 30-day prescription, it can be filled at any network retail pharmacy or network home delivery pharmacy. If you choose to fill a 90-day prescription, it must be filled at a 90-day network retail pharmacy or network home delivery pharmacy to be covered by the plan. Specialty medications are used to treat an underlying disease which is considered to be rare and chronic including, but not limited to, multiple sclerosis, hepatitis C or rheumatoid arthritis. Specialty Drugs may include high cost medications as well as medications that may require special handling and close supervision when being administered. When patient requests brand drug, patient pays the brand cost share plus the cost difference between the brand and generic drugs up to the cost of the brand drug (unless the physician indicates "Dispense As Written" DAW). Your pharmacy benefits share an out-of-pocket maximum with the medical/behavioral benefits. Specialty Drugs provided at Home Delivery at the Retail (per 30-day supply) cost share.
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Prescription Drug List: Your Cigna Standard Prescription Drug List includes a full range of drugs including all those required under applicable health care laws. To check which drugs are included in your plan, please log on to myCigna.com. Some highlights: Coverage includes Self Administered injectables and optional injectable drugs – but excludes infertility drugs. Contraceptive devices and drugs are covered with federally required products covered at 100%. Insulin, glucose test strips, lancets, insulin needles & syringes, insulin pens and cartridges are covered.
Drugs Covered
Cigna Pharmacy Cost Share Retail – up to 90-day supply (except Specialty up to 30-day supply) Home Delivery – up to 90-day supply (except Specialty up to 30-day supply)
Pharmacy Cost Share and Supply
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Case Management Coordinated by Cigna HealthCare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective care while maximizing the patient's quality of life. Comprehensive Oncology Program Care Management outreach Included Case Management Healthy Pregnancies/Healthy Babies Care Management outreach $150 (1st trimester) / $75 (2nd trimester) - Option 3 Maternity Case Management Neo-natal Case Management
Additional Information
Pharmacy Clinical Management: Essential Your plan features drug management programs and edits to ensure safe prescribing, and access to medications proven to be the most reliable and cost effective for the medical condition, including: Prior authorization requirements Step Therapy on select classes of medications and drugs new to the market Quantity limits, including maximum daily dose edits, quantity over time edits, duration of therapy edits, and dose optimization edits Age edits, and refill-too-soon edits Plan exclusion edits Current users of Step Therapy medications will be allowed one 30-day fill during the first three months of coverage before Step Therapy program applies. Your plan includes Specialty Drug Management features, such as prior authorization and quantity limits, to ensure the safe prescribing and access to specialty medications. For customers with complex conditions taking a specialty medication, we will offer Accredo Therapeutic Resource Centers (TRCs) to provide specialty medication and condition counseling. For customers taking a specialty medication not dispensed by Accredo, Cigna experts will offer this important specialty medication and condition counseling.
Pharmacy Program Information
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Additional Information
Maximum Reimbursable Charge The allowable covered expense for non-network services is based on the lesser of the health care professional's normal charge for a similar service or a percentage of a fee schedule (110%) developed by Cigna that is based on a methodology similar to one used by Medicare to determine the allowable fee for the same or similar service in a geographic area. In some cases, the Medicare based fee schedule will not be used and the maximum reimbursable charge for covered services is based on the lesser of the health care professional's normal charge for a similar service or a percentile (80th) of charges made by health care professionals of such service or supply in the geographic area where it is received. If sufficient charge data is unavailable in the database for that geographic area to determine the Maximum Reimbursable Charge, then data in the database for similar services may be used. Out-of-network services are subject to a Contract Year deductible and maximum reimbursable charge limitations.
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When a person is eligible for Medicare A and B as described above, this plan will pay as the Secondary Plan to Medicare Part A and B regardless if the person is actually enrolled in Medicare Part A and/or Part B and regardless if the person seeks care at a Medicare Provider or not for Medicare covered services. Multiple Surgical Reduction Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery. One Guide Available by phone or through myCigna mobile application. One Guide helps you navigate the health care system and make the most of your health benefits and programs.
The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is also responsible for all charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card. Medicare Coordination In accordance with the Social Security Act of 1965, this plan will pay as the Secondary plan to Medicare Part A and B as follows: (a) a former Employee such as a retiree, a former Disabled Employee, a former Employee's Dependent, or an Employee's Domestic Partner who is also eligible for Medicare and whose insurance is continued for any reason as provided in this plan (including COBRA continuation); (b) an Employee, a former Employee, an Employee’s Dependent, or former Employee’s Dependent, who is eligible for Medicare due to End Stage Renal Disease after that person has been eligible for Medicare for 30 months.
Out-of-Network Emergency Services Charges 1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-participating (Out-of-Network) provider. 2. The allowable amount used to determine the Plan's benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-ofNetwork provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or if no amount is agreed to, the greater of the following: (i) the median amount negotiated with In-Network providers for the Emergency Service, excluding any In-Network copay or coinsurance; (ii) the Maximum Reimbursable Charge; or (iii) the amount payable under the Medicare program, not to exceed the provider's billed charges.
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Additional Information
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©Cigna 2021
Pre-Certification - Continued Stay Review - Preferred Care Management Inpatient - required for all inpatient admissions In-Network: Coordinated by your physician Out-of-Network: Customer is responsible for contacting Cigna Healthcare. Subject to penalty/reduction or denial for non-compliance. 50% penalty applied to hospital inpatient charges for failure to contact Cigna Healthcare to precertify admission. Benefits are denied for any admission reviewed by Cigna Healthcare and not certified. Benefits are denied for any additional days not certified by Cigna Healthcare. Pre-Certification - Preferred Care Management Outpatient Prior Authorization - required for selected outpatient procedures and diagnostic testing In-Network: Coordinated by your physician Out-of-Network: Customer is responsible for contacting Cigna Healthcare. Subject to penalty/reduction or denial for non-compliance. 50% penalty applied to outpatient procedures/diagnostic testing charges for failure to contact Cigna Healthcare and to precertify admission. Benefits are denied for any outpatient procedures/diagnostic testing reviewed by Cigna Healthcare and not certified. Pre-Existing Condition Limitation (PCL) does not apply. Holistic health support for the following chronic health conditions: Heart Disease Coronary Artery Disease Angina Your Health First - 200 Congestive Heart Failure Individuals with one or more of the chronic conditions, identified on the right, may be eligible to receive the following type of support: Acute Myocardial Infarction Peripheral Arterial Disease Condition Management Asthma Medication adherence Chronic Obstructive Pulmonary Disease (Emphysema and Chronic Risk factor management Bronchitis) Lifestyle issues Diabetes Type 1 Health & Wellness issues Diabetes Type 2 Pre/post-admission Metabolic Syndrome/Weight Complications Treatment decision support Osteoarthritis Gaps in care Low Back Pain Anxiety Bipolar Disorder Depression
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Coinsurance - After you've reached your deductible, you and your plan share some of your medical costs. The portion of covered expenses you are responsible for is called Coinsurance. Copay - A flat fee you pay for certain covered services such as doctor's visits or prescriptions. Deductible - A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered services. Out-of-Pocket Maximum - Specific limits for the total amount you will pay out of your own pocket before your plan coinsurance percentage no longer applies. Once you meet these maximums, your plan then pays 100 percent of the "Maximum Reimbursable Charges" or negotiated fees for covered services. Place of Service - Your plan pays based on where you receive services. For example, for hospital stays, your coverage is paid at the inpatient level. Prescription Drug List - The list of prescription brand and generic drugs covered by your pharmacy plan. Professional Services - Services performed by Surgeons, Assistant Surgeons, Hospital Based Physicians, Radiologists, Pathologists and Anesthesiologists Transition of Care - Provides in-network health coverage to new customers when the customer's doctor is not part of the Cigna network and there are approved clinical reasons why the customer should continue to see the same doctor.
Definitions
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©Cigna 2021
What's Not Covered (not all-inclusive): Your plan provides for most medically necessary services. The complete list of exclusions is provided in your Certificate or Summary Plan Description. To the extent there may be differences, the terms of the Certificate or Summary Plan Description control. Examples of things your plan does not cover, unless required by law or covered under the pharmacy benefit, include (but aren't limited to): Care for health conditions that are required by state or local law to be treated in a public facility. Care required by state or federal law to be supplied by a public school system or school district. Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available. Treatment of an Injury or Sickness which is due to war, declared, or undeclared. Charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan. For example, if Cigna determines that a provider or Pharmacy is or has waived, reduced, or forgiven any portion of its charges and/or any portion of Copayment, Deductible, and/or Coinsurance amount(s) you are required to pay for a Covered Expense (as shown on The Schedule) without Cigna's express consent, then Cigna shall have the right to deny the payment of benefits in connection with the Covered Expense, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider or Pharmacy represents that you remain responsible for any amounts that your plan does not cover. Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a non-Participating Provider who has agreed to charge you or charged you at an In-Network benefits level or some other benefits level not otherwise applicable to the services received. Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care. For or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be: o Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed; o Not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed; o The subject of review or approval by an Institutional Review Board for the proposed use except as provided in the "Clinical Trials" sections of this plan; or
Exclusions
42
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©Cigna 2021
The subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the "Clinical Trials" sections of this plan. o In determining whether any such technologies, supplies, treatments, drug or Biologic therapies, or devices are experimental, investigational, and/or unproven, the utilization review Physician may rely on the clinical coverage policies maintained by Cigna or the Review Organization. Clinical coverage policies may incorporate, without limitation and as applicable, criteria relating to U.S. Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scientific literature or guidelines. Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem. The following services are excluded from coverage regardless of clinical indications: macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty; panniculectomy; rhinoplasty; blepharoplasty; redundant skin surgery; removal of skin tags; acupressure; craniosacral/cranial therapy; dance therapy; movement therapy; applied kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, except as may be covered under the "Reconstructive Surgery" benefit. Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. Charges made for services or supplies provided for or in connection with an accidental Injury to teeth are covered provided a continuous course of dental treatment is started within six months of an accident. For medical and surgical services, initial and repeat, intended for the treatment or control of obesity including clinically severe (morbid) obesity, including: medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a Physician or under medical supervision. Unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations. Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan. Infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage. Reversal of male or female voluntary sterilization procedures. Any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation. Non-medical counseling or ancillary services, including but not limited to Custodial Services, educational services, vocational counseling, training and, rehabilitation services, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, return to work services, work hardening programs and, driving safety courses. Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected. Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the "Home Health Services" or "Breast Reconstruction and Breast Prostheses" sections of this plan. Private Hospital rooms and/or private duty nursing except as provided under the Home Health Services provision. Personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness. Artificial aids including, but not limited to, garter belts, corsets, dentures and wigs. Aids or devices that assist with non-verbal communications, including but not limited to communication boards, pre-recorded speech devices, laptop
o
Exclusions
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computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books. Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post cataract surgery). Routine refractions, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy. Treatment by acupuncture. All non-injectable prescription drugs unless Physician administration or oversight is required, injectable prescription drugs to the extent they do not require Physician supervision and are typically considered self-administered drugs, non-prescription drugs, and investigational and experimental drugs, except as provided in this plan. Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary. Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs. Genetic screening or pre-implantations genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease. Dental implants for any condition. Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review Physician's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement in physical condition. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks. Cosmetics, dietary supplements and health and beauty aids. All nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism. Medical treatment when payment is denied by a Primary Plan because treatment was received from a non-Participating Provider. For or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit. Charges for the delivery of medical and health-related services via telecommunications technologies, including telephone and internet unless provided as specifically described under Covered Expenses. Massage therapy. Abortions, unless a Physician certifies in writing that the pregnancy would endanger the life of the mother, or the expenses are incurred to treat medical complications due to abortion.
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EHB State: TX
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©Cigna 2021
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
These are only the highlights This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including benefits required by your state, see your employer's insurance certificate, service agreement or summary plan description -- the official plan documents. If there are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Exclusions
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If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file
• Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.
Cigna:
Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Medical coverage
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 http://www.hhs.gov/ocr/office/file/index.html.
If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Cigna Nondiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422
a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:
DISCRIMINATION IS AGAINST THE LAW
896375a 05/17
© 2017 Cigna.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
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English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).
Proficiency of Language Assistance Services
Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).
Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).
Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna,
896375a 05/17
Cigna لعمالء. – برجاء االنتباه خدمات الترجمة المجانية متاحة لكمArabic او اتصل ب.الحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصية .)711 اتصل ب:TTY( 1.800.244.6224
برای. به صورت رایگان به شما ارائه میشود٬ خدمات کمک زبانی: – توجهPersian (Farsi) در غیر. لطفا ً با شمارهای که در پشت کارت شناسایی شماست تماس بگیرید٬Cigna مشتریان فعلی را711 شماره: تماس بگیرید (شماره تلفن ویژه ناشنوایان1.800.244.6224 اینصورت با شماره .)شمارهگیری کنید
Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利 用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電 話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711） まで、お電話にてご連絡ください。
Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.
позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).
Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).
Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).
French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).
French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).
Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).
Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。
Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
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BENEFIT SUMMARY
Plan Highlights
In-Network
Out-of-Network
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Unlimited Unlimited Your Plan’s Deductibles, Out-of-Pockets and benefit level limits accumulate on a contract year basis unless otherwise stated. In addition, all plan maximums and servicePlan Year Accumulation specific maximums (dollar and occurrence) cross-accumulate between In- and Out-ofNetwork unless otherwise noted. Plan Coinsurance Plan pays 80% Plan pays 60% Maximum Reimbursable Charge Not Applicable 110% Individual: $1,000 Individual: $2,000 Plan Deductible Family: $2,000 Family: $4,000 Only the amount you pay for in-network covered expenses counts towards your in-network deductible. Only the amount you pay for out-of-network covered expenses counts towards your out-of-network deductible. Benefit copays/deductibles always apply before plan deductible and coinsurance. Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance. Note: Services where plan deductible applies are noted with a caret (^).
Lifetime Maximum
Cigna Health and Life Insurance Co. For - Lifeschool of Dallas Open Access Plus Plan OAP Buy-Up $1,000 Deductible Effective - 09/01/2021 Selection of a Primary Care Provider - your plan may require or allow the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. If your plan requires designation of a primary care provider, Cigna may designate one for you until you make this designation. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider. Direct Access to Obstetricians and Gynecologists - You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. A notice for Texas residents: This plan does not include an optional rider to cover elective abortions.
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Plan Highlights
In-Network
Out-of-Network
In-Network
Out-of-Network
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Preventive Care
Plan pays 100%
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©Cigna 2021
PCP: Plan pays 60% ^ Specialist: Plan pays 60% ^ Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit when billed as part of office visit. Annual Limit: Unlimited
Preventive Care
Primary Care Physician (PCP) Services/Office Visit Plan pays 100% Plan pays 60% ^ Specialty Care Physician Services/Office Visit $40 copay, and plan pays 100% Plan pays 60% ^ NOTE: Obstetrician and Gynecologist (OB/GYN) visits are subject to either the PCP or Specialist cost share depending on how the provider contracts with Cigna (i.e. as PCP or as Specialist). Covered same as Physician Services Covered same as Physician Services Surgery Performed in Physician's Office Office Visit Office Visit Allergy Treatment/Injections and Allergy Serum Covered same as Physician Services Covered same as Physician Services Allergy serum dispensed by the physician in the office Office Visit Office Visit Note: Office copay does not apply if only the allergy serum is provided. Cigna Telehealth Connection Services (Virtual Care) Plan pays 100% Not Covered Includes charges for the delivery of medical and health-related services and consultations by dedicated virtual providers as medically appropriate through audio, video, and secure internet-based technologies. Virtual Wellness Screenings are available for individuals 18 and older and are covered same as Preventive Care (see Preventive Care Section). Telehealth services rendered by providers that are not contracted medical telehealth providers (as described on myCigna.com) are covered at the same benefit level as the same services would be if rendered in-person.
Physician Services - Office Visits
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
Benefit
Individual: $3,000 Individual: $6,000 Plan Out-of-Pocket Maximum Family: $6,000 Family: $12,000 Only the amount you pay for in-network covered expenses counts toward your in-network out-of-pocket maximum. Only the amount you pay for out-of-network covered expenses counts toward your out-of-network out-of-pocket maximum. Plan deductible contributes towards your out-of-pocket maximum. All benefit copays/deductibles contribute towards your out-of-pocket maximum. Covered expenses that count towards your out-of-pocket maximum include customer paid coinsurance and charges for Mental Health and Substance Use Disorder. Out-of-network non-compliance penalties or charges in excess of Maximum Reimbursable Charge do not contribute towards the out-of-pocket maximum. After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member's covered expenses. This plan includes a combined Medical/Pharmacy out-of-pocket maximum.
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Benefit
In-Network
Out-of-Network
PCP: Plan pays 60% ^ Specialist: Plan pays 60% ^ Covered same as other x-ray and lab services, based on Place of Service
Plan pays 60% ^ Plan pays 60% ^
Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities Annual Limit: 60 days
Inpatient Services at Other Health Care Facilities
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Plan pays 100%
Plan pays 60% ^
©Cigna 2021
Emergency Room Includes Professional, X-ray and/or Lab services performed at the $250 copay, and plan pays 80% $250 copay, and plan pays 80% Emergency Room and billed by the facility as part of the ER visit. Per visit copay is waived if admitted. Urgent Care Facility Includes Professional, X-ray and/or Lab services performed at the $75 copay, and plan pays 100% $75 copay, and plan pays 100% Urgent Care Facility and billed by the facility as part of the urgent care visit. Ambulance Plan pays 80% ^ Plan pays 80% ^ Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered.
Emergency Services
Outpatient Facility Services Plan pays 80% ^ Outpatient Professional Services Plan pays 80% ^ For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists
Outpatient
Inpatient Hospital Facility Services Plan pays 80% ^ Plan pays 60% ^ Note: Includes all Lab and Radiology services, including Advanced Radiological Imaging as well as Medical Specialty Drugs Inpatient Hospital Physician's Visit/Consultation Plan pays 80% ^ Plan pays 60% ^ Inpatient Professional Services Plan pays 80% ^ Plan pays 60% ^ For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists
Inpatient
Coverage includes the associated Preventive Outpatient Professional Services. Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on Place of Service.
Plan pays 100%
Mammogram, PAP, and PSA Tests
Plan pays 100%
Ages 6 and older
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible. Immunizations Plan pays 100% Plan pays 100% Birth through age 5
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Benefit
In-Network
Out-of-Network
Laboratory Services
Plan pays 80% ^
Covered same as Physician Services Office Visit
Plan pays 60% ^ Plan pays 60% ^
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Services Provided by a Mental Health Professional
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Covered under Mental Health benefit
©Cigna 2021
Covered under Mental Health benefit
Bereavement Counseling (for services not provided as part of a hospice program)
Inpatient Facilities Plan pays 100% Outpatient Services Plan pays 100% Note: Includes Bereavement counseling provided as part of a hospice program.
Hospice
Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum. Covered same as Physician Services Cardiac Rehabilitation Services Plan pays 80% ^ Office Visit Annual Limit: Cardiac Rehabilitation - 36 days
Annual Limits: All Therapies Combined - Includes Chiropractic Care, Cognitive Therapy, Occupational Therapy, Physical Therapy, Pulmonary Rehabilitation, and Speech Therapy - 35 days Limits are not applicable to mental health conditions for Physical, Speech and Occupational Therapies.
Outpatient Therapy and Chiropractic Services
Outpatient Therapy Services
Physician’s Services/Office Visit
Plan pays 60% ^ Covered same as Physician Services Office Visit
Plan pays 80% ^ Covered same as Physician Services Office Visit
Outpatient Facility
Covered same as Physician Services Office Visit Plan pays 60% ^
Includes MRI, MRA, CAT Scan, PET Scan, etc.
Covered same as Physician Services Office Visit Plan pays 100%
Covered same as Physician Services Office Visit Plan pays 60% ^ Plan pays 60% ^
Advanced Radiological Imaging (ARI)
Outpatient Facility
Physician’s Services/Office Visit
Radiology Services
Independent Lab Outpatient Facility
Physician’s Services/Office Visit
Covered same as Physician Services Office Visit Plan pays 100% Plan pays 100%
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
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Benefit
In-Network
Out-of-Network
Plan pays 80% ^ Plan pays 80% ^
Physician's Office
Home
Plan pays 60% ^
Plan pays 60% ^
Plan pays 60% ^
Plan pays 100%
Coverage varies based on Place of Service
Covered same as Physician Services Office Visit Covered same as plan’s Inpatient Hospital benefit
Covered same as Physician Services Office Visit Covered same as plan’s Inpatient Hospital benefit Coverage varies based on Place of Service
Plan pays 60% ^
Covered same as Physician Services Office Visit
Plan pays 80% ^
Covered same as Physician Services Office Visit
Women’s Services
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Coverage varies based on Place of Service Includes contraceptive devices as ordered or prescribed by a physician and surgical sterilization services, such as tubal ligation (excludes reversals) Coverage varies based on Place of Coverage varies based on Place of Men’s Services Service Service Includes surgical sterilization services, such as vasectomy (excludes reversals)
Family Planning
Note: Non-elective procedures only
Abortion Services
Abortion
All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges (Global Maternity Fee) Office Visits in Addition to Global Maternity Fee (Performed by OB/GYN or Specialist) Delivery - Facility (Inpatient Hospital, Birthing Center)
Initial Visit to Confirm Pregnancy
Maternity
Note: This benefit only applies to the cost of the Infusion Therapy drugs administered. This benefit does not cover the related Facility, Office Visit or Professional charges.
Plan pays 80% ^
Outpatient Facility
Medical Specialty Drugs
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
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Benefit
In-Network
Out-of-Network
Infertility
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.
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Travel Maximum - $10,000 maximum per Transplant per Lifetime Durable Medical Equipment Annual Limit: Unlimited Breast Feeding Equipment and Supplies Limited to the rental of one breast pump per birth as ordered or prescribed by a physician Includes related supplies External Prosthetic Appliances (EPA) Annual Limit: Unlimited
Non-LifeSOURCE Facility
Plan pays 60% ^ Plan pays 60% ^
Plan pays 100% Plan pays 80% ^
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Plan pays 60% ^
Bone Marrow - $130,000 Heart - $150,000 Heart/Lung - $185,000 Kidney - $80,000 Kidney/Pancreas - $80,000 Liver - $230,000 Lung - $185,000 Pancreas - $50,000
©Cigna 2021
Not Applicable Covered same as plan's Inpatient Professional benefit up to the following transplant maximums:
Not Applicable Covered same as plan’s Inpatient Hospital benefit
Plan pays 60% ^
Plan pays 80% ^
Covered same as plan’s Inpatient Professional benefit
Home Health Care Plan pays 100% Annual Limit: 60 days (The limit is not applicable to mental health and substance use disorder conditions.) 16 hour maximum per day Note: Includes outpatient private duty nursing when approved as medically necessary Organ Transplants Inpatient Hospital Facility Services LifeSOURCE Facility Plan pays 100% Covered same as plan’s Inpatient Hospital Non-LifeSOURCE Facility benefit Inpatient Professional Services LifeSOURCE Facility Plan pays 100%
Other Health Care Facilities/Services
Infertility Treatment Note: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness.
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Benefit
In-Network
Out-of-Network
Plan pays 80% ^ Plan pays 100% Plan pays 80% ^ Plan pays 80% ^ Plan pays 100% Plan pays 80% ^
Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^ Plan pays 60% ^
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Cigna Total Behavioral Health - Inpatient and Outpatient Management Inpatient utilization review and case management Outpatient utilization review and case management Partial Hospitalization Intensive outpatient programs Changing Lives by Integrating Mind and Body Program Lifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management. Narcotic Therapy Management Complex Psychiatric Case Management
©Cigna 2021
Notes: Inpatient includes Acute Inpatient and Residential Treatment. Outpatient - Physician's Office - may include Individual, family and group therapy, psychotherapy, medication management, etc. Outpatient - All Other Services - may include Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy), etc. Services are paid at 100% after you reach your out-of-pocket maximum. Mental Health/Substance Use Disorder Utilization Review, Case Management and Programs
Inpatient Mental Health Outpatient Mental Health – Physician’s Office Outpatient Mental Health – All Other Services Inpatient Substance Use Disorder Outpatient Substance Use Disorder – Physician’s Office Outpatient Substance Use Disorder – All Other Services Annual Limits: Unlimited maximum
Mental Health and Substance Use Disorder
Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible. Temporomandibular Joint Disorder (TMJ) Coverage varies based on Place of Coverage varies based on Place of Service Service Unlimited lifetime maximum Note: Provided on a limited, case-by-case basis. Excludes appliances and orthodontic treatment. Routine Foot Care Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Hearing Aids Plan pays 80% ^ Plan pays 60% ^ Maximum of 2 devices (one per ear) per 36 months Includes testing and fitting of hearing aid devices at Physician Office Visit cost share Coverage through age 18
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Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $100 Non-Preferred Brand: You pay $175
Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70
In-Network
Home Delivery: Same as Retail Out-of-Network
Retail: You pay 30% Your plan pays 70%
Out-of-Network
Retail drugs for a 30 day supply may be obtained In-Network at a wide range of pharmacies across the nation although prescriptions for a 90 day supply (such as maintenance drugs) will be available at select network pharmacies. Cigna 90 Now Program: You can choose to fill your medications in a 30- or 90-day supply. If you choose to fill a 30-day prescription, it can be filled at any network retail pharmacy or network home delivery pharmacy. If you choose to fill a 90-day prescription, it must be filled at a 90-day network retail pharmacy or network home delivery pharmacy to be covered by the plan. Specialty medications are used to treat an underlying disease which is considered to be rare and chronic including, but not limited to, multiple sclerosis, hepatitis C or rheumatoid arthritis. Specialty Drugs may include high cost medications as well as medications that may require special handling and close supervision when being administered. When patient requests brand drug, patient pays the brand cost share plus the cost difference between the brand and generic drugs up to the cost of the brand drug (unless the physician indicates "Dispense As Written" DAW). Your pharmacy benefits share an out-of-pocket maximum with the medical/behavioral benefits. Specialty Drugs provided at Home Delivery at the Retail (per 30-day supply) cost share.
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Prescription Drug List: Your Cigna Standard Prescription Drug List includes a full range of drugs including all those required under applicable health care laws. To check which drugs are included in your plan, please log on to myCigna.com. Some highlights: Coverage includes Self Administered injectables and optional injectable drugs – but excludes infertility drugs. Contraceptive devices and drugs are covered with federally required products covered at 100%. Insulin, glucose test strips, lancets, insulin needles & syringes, insulin pens and cartridges are covered.
Drugs Covered
Cigna Pharmacy Cost Share Retail – up to 90-day supply (except Specialty up to 30-day supply) Home Delivery – up to 90-day supply (except Specialty up to 30-day supply)
Pharmacy Cost Share and Supply
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Case Management Coordinated by Cigna HealthCare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective care while maximizing the patient's quality of life. Comprehensive Oncology Program Care Management outreach Included Case Management Healthy Pregnancies/Healthy Babies Care Management outreach $150 (1st trimester) / $75 (2nd trimester) - Option 3 Maternity Case Management Neo-natal Case Management
Additional Information
Pharmacy Clinical Management: Essential Your plan features drug management programs and edits to ensure safe prescribing, and access to medications proven to be the most reliable and cost effective for the medical condition, including: Prior authorization requirements Step Therapy on select classes of medications and drugs new to the market Quantity limits, including maximum daily dose edits, quantity over time edits, duration of therapy edits, and dose optimization edits Age edits, and refill-too-soon edits Plan exclusion edits Current users of Step Therapy medications will be allowed one 30-day fill during the first three months of coverage before Step Therapy program applies. Your plan includes Specialty Drug Management features, such as prior authorization and quantity limits, to ensure the safe prescribing and access to specialty medications. For customers with complex conditions taking a specialty medication, we will offer Accredo Therapeutic Resource Centers (TRCs) to provide specialty medication and condition counseling. For customers taking a specialty medication not dispensed by Accredo, Cigna experts will offer this important specialty medication and condition counseling.
Pharmacy Program Information
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Additional Information
Maximum Reimbursable Charge The allowable covered expense for non-network services is based on the lesser of the health care professional's normal charge for a similar service or a percentage of a fee schedule (110%) developed by Cigna that is based on a methodology similar to one used by Medicare to determine the allowable fee for the same or similar service in a geographic area. In some cases, the Medicare based fee schedule will not be used and the maximum reimbursable charge for covered services is based on the lesser of the health care professional's normal charge for a similar service or a percentile (80th) of charges made by health care professionals of such service or supply in the geographic area where it is received. If sufficient charge data is unavailable in the database for that geographic area to determine the Maximum Reimbursable Charge, then data in the database for similar services may be used. Out-of-network services are subject to a Contract Year deductible and maximum reimbursable charge limitations.
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When a person is eligible for Medicare A and B as described above, this plan will pay as the Secondary Plan to Medicare Part A and B regardless if the person is actually enrolled in Medicare Part A and/or Part B and regardless if the person seeks care at a Medicare Provider or not for Medicare covered services. Multiple Surgical Reduction Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery. One Guide Available by phone or through myCigna mobile application. One Guide helps you navigate the health care system and make the most of your health benefits and programs.
The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is also responsible for all charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card. Medicare Coordination In accordance with the Social Security Act of 1965, this plan will pay as the Secondary plan to Medicare Part A and B as follows: (a) a former Employee such as a retiree, a former Disabled Employee, a former Employee's Dependent, or an Employee's Domestic Partner who is also eligible for Medicare and whose insurance is continued for any reason as provided in this plan (including COBRA continuation); (b) an Employee, a former Employee, an Employee’s Dependent, or former Employee’s Dependent, who is eligible for Medicare due to End Stage Renal Disease after that person has been eligible for Medicare for 30 months.
Out-of-Network Emergency Services Charges 1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-participating (Out-of-Network) provider. 2. The allowable amount used to determine the Plan's benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-ofNetwork provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or if no amount is agreed to, the greater of the following: (i) the median amount negotiated with In-Network providers for the Emergency Service, excluding any In-Network copay or coinsurance; (ii) the Maximum Reimbursable Charge; or (iii) the amount payable under the Medicare program, not to exceed the provider's billed charges.
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Additional Information
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©Cigna 2021
Pre-Certification - Continued Stay Review - Preferred Care Management Inpatient - required for all inpatient admissions In-Network: Coordinated by your physician Out-of-Network: Customer is responsible for contacting Cigna Healthcare. Subject to penalty/reduction or denial for non-compliance. 50% penalty applied to hospital inpatient charges for failure to contact Cigna Healthcare to precertify admission. Benefits are denied for any admission reviewed by Cigna Healthcare and not certified. Benefits are denied for any additional days not certified by Cigna Healthcare. Pre-Certification - Preferred Care Management Outpatient Prior Authorization - required for selected outpatient procedures and diagnostic testing In-Network: Coordinated by your physician Out-of-Network: Customer is responsible for contacting Cigna Healthcare. Subject to penalty/reduction or denial for non-compliance. 50% penalty applied to outpatient procedures/diagnostic testing charges for failure to contact Cigna Healthcare and to precertify admission. Benefits are denied for any outpatient procedures/diagnostic testing reviewed by Cigna Healthcare and not certified. Pre-Existing Condition Limitation (PCL) does not apply. Holistic health support for the following chronic health conditions: Heart Disease Coronary Artery Disease Angina Your Health First - 200 Congestive Heart Failure Individuals with one or more of the chronic conditions, identified on the right, may be eligible to receive the following type of support: Acute Myocardial Infarction Peripheral Arterial Disease Condition Management Asthma Medication adherence Chronic Obstructive Pulmonary Disease (Emphysema and Chronic Risk factor management Bronchitis) Lifestyle issues Diabetes Type 1 Health & Wellness issues Diabetes Type 2 Pre/post-admission Metabolic Syndrome/Weight Complications Treatment decision support Osteoarthritis Gaps in care Low Back Pain Anxiety Bipolar Disorder Depression
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Coinsurance - After you've reached your deductible, you and your plan share some of your medical costs. The portion of covered expenses you are responsible for is called Coinsurance. Copay - A flat fee you pay for certain covered services such as doctor's visits or prescriptions. Deductible - A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered services. Out-of-Pocket Maximum - Specific limits for the total amount you will pay out of your own pocket before your plan coinsurance percentage no longer applies. Once you meet these maximums, your plan then pays 100 percent of the "Maximum Reimbursable Charges" or negotiated fees for covered services. Place of Service - Your plan pays based on where you receive services. For example, for hospital stays, your coverage is paid at the inpatient level. Prescription Drug List - The list of prescription brand and generic drugs covered by your pharmacy plan. Professional Services - Services performed by Surgeons, Assistant Surgeons, Hospital Based Physicians, Radiologists, Pathologists and Anesthesiologists Transition of Care - Provides in-network health coverage to new customers when the customer's doctor is not part of the Cigna network and there are approved clinical reasons why the customer should continue to see the same doctor.
Definitions
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©Cigna 2021
What's Not Covered (not all-inclusive): Your plan provides for most medically necessary services. The complete list of exclusions is provided in your Certificate or Summary Plan Description. To the extent there may be differences, the terms of the Certificate or Summary Plan Description control. Examples of things your plan does not cover, unless required by law or covered under the pharmacy benefit, include (but aren't limited to): Care for health conditions that are required by state or local law to be treated in a public facility. Care required by state or federal law to be supplied by a public school system or school district. Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available. Treatment of an Injury or Sickness which is due to war, declared, or undeclared. Charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan. For example, if Cigna determines that a provider or Pharmacy is or has waived, reduced, or forgiven any portion of its charges and/or any portion of Copayment, Deductible, and/or Coinsurance amount(s) you are required to pay for a Covered Expense (as shown on The Schedule) without Cigna's express consent, then Cigna shall have the right to deny the payment of benefits in connection with the Covered Expense, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider or Pharmacy represents that you remain responsible for any amounts that your plan does not cover. Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a non-Participating Provider who has agreed to charge you or charged you at an In-Network benefits level or some other benefits level not otherwise applicable to the services received. Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care. For or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be: o Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed; o Not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed; o The subject of review or approval by an Institutional Review Board for the proposed use except as provided in the "Clinical Trials" sections of this plan; or
Exclusions
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©Cigna 2021
The subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the "Clinical Trials" sections of this plan. o In determining whether any such technologies, supplies, treatments, drug or Biologic therapies, or devices are experimental, investigational, and/or unproven, the utilization review Physician may rely on the clinical coverage policies maintained by Cigna or the Review Organization. Clinical coverage policies may incorporate, without limitation and as applicable, criteria relating to U.S. Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scientific literature or guidelines. Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem. The following services are excluded from coverage regardless of clinical indications: macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty; panniculectomy; rhinoplasty; blepharoplasty; redundant skin surgery; removal of skin tags; acupressure; craniosacral/cranial therapy; dance therapy; movement therapy; applied kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, except as may be covered under the "Reconstructive Surgery" benefit. Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. Charges made for services or supplies provided for or in connection with an accidental Injury to teeth are covered provided a continuous course of dental treatment is started within six months of an accident. For medical and surgical services, initial and repeat, intended for the treatment or control of obesity including clinically severe (morbid) obesity, including: medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a Physician or under medical supervision. Unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations. Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan. Infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage. Reversal of male or female voluntary sterilization procedures. Any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation. Non-medical counseling or ancillary services, including but not limited to Custodial Services, educational services, vocational counseling, training and, rehabilitation services, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, return to work services, work hardening programs and, driving safety courses. Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected. Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the "Home Health Services" or "Breast Reconstruction and Breast Prostheses" sections of this plan. Private Hospital rooms and/or private duty nursing except as provided under the Home Health Services provision. Personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness. Artificial aids including, but not limited to, garter belts, corsets, dentures and wigs. Aids or devices that assist with non-verbal communications, including but not limited to communication boards, pre-recorded speech devices, laptop
o
Exclusions
59
computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books. Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post cataract surgery). Routine refractions, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy. Treatment by acupuncture. All non-injectable prescription drugs unless Physician administration or oversight is required, injectable prescription drugs to the extent they do not require Physician supervision and are typically considered self-administered drugs, non-prescription drugs, and investigational and experimental drugs, except as provided in this plan. Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary. Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs. Genetic screening or pre-implantations genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease. Dental implants for any condition. Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review Physician's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement in physical condition. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks. Cosmetics, dietary supplements and health and beauty aids. All nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism. Medical treatment when payment is denied by a Primary Plan because treatment was received from a non-Participating Provider. For or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit. Charges for the delivery of medical and health-related services via telecommunications technologies, including telephone and internet unless provided as specifically described under Covered Expenses. Massage therapy. Abortions, unless a Physician certifies in writing that the pregnancy would endanger the life of the mother, or the expenses are incurred to treat medical complications due to abortion.
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EHB State: TX
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©Cigna 2021
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
These are only the highlights This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including benefits required by your state, see your employer's insurance certificate, service agreement or summary plan description -- the official plan documents. If there are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Exclusions
60
If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file
• Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.
Cigna:
Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Medical coverage
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 http://www.hhs.gov/ocr/office/file/index.html.
If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Cigna Nondiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422
a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:
DISCRIMINATION IS AGAINST THE LAW
896375a 05/17
© 2017 Cigna.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
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English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).
Proficiency of Language Assistance Services
Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).
Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).
Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna,
896375a 05/17
Cigna لعمالء. – برجاء االنتباه خدمات الترجمة المجانية متاحة لكمArabic او اتصل ب.الحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصية .)711 اتصل ب:TTY( 1.800.244.6224
برای. به صورت رایگان به شما ارائه میشود٬ خدمات کمک زبانی: – توجهPersian (Farsi) در غیر. لطفا ً با شمارهای که در پشت کارت شناسایی شماست تماس بگیرید٬Cigna مشتریان فعلی را711 شماره: تماس بگیرید (شماره تلفن ویژه ناشنوایان1.800.244.6224 اینصورت با شماره .)شمارهگیری کنید
Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利 用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電 話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711） まで、お電話にてご連絡ください。
Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.
позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).
Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).
Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).
French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).
French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).
Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).
Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。
Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
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63
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 64 details on covered expenses,Frisco limitations and exclusions included in the summary plan description located on the ISD Benefits Website:are www.mybenefitshub.com/friscoisd Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
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 2021 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,600 us online at eecu.org or use our secure email. Member Family: $7,200 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 printed statements. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation. Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.
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NBS
FSA (Flexible Spending Account)
YOUR BENEFITS PACKAGE
About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.
Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.
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 66 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
FSA (Flexible Spending Account) How do I receive reimbursements? During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are Congratulations! considered "incurred" when the service is performed, not Your employer has established a "flexible benefits plan" to help necessarily when it is paid for. You can get submit a claim online you pay for your out-of-pocket health and daycare expenses. at: my.nbsbenefits.com One of the most important features of the plan is that the Please note: Policies other than company sponsored policies (i.e. benefits being offered are paid for with a portion of your pay spouse’s or dependents’ individual policies) may not be paid before federal income or social security taxes are withheld. This through the flexible beneits plan. Furthermore, qualified longmeans that you will pay less tax and have more money to spend term care insurance plans may not be paid through the flexible and save. However, if you receive a reimbursement for an benefits plan. expense under the plan, you cannot claim a federal income tax NBS Benefits Card credit or deduction on your return. Your employer may Health Flexible spending account: sponsor the use of the The health flexible spending account (FSA) enables you to pay NBS Benefits Card, for expenses allowed under Section 105 and 213(d) of the making access to your Internal Revenue Code which are not covered by our insured flex dollars easier than medical plan. ever. You may use the The most that you can contribute to your Health FSA each plan card to pay merchants year is set by the IRS. This amount can be adjusted for increases or service providers in cost-of-living in accordance with Code Section 125(i)(2). that accept credit cards such as hospitals and pharmacies, so there is no need to pay cash up front then wait for Premium expense plan: reimbursement. A premium expense portion of the plan allows you to use preOrthodontic expenses that are paid fully up-front at the time of tax dollars to pay for specific premiums under various insurance initial service are reimbursable in full after the initial service has programs we offer you. been performed and payment has been made. Ongoing orthodontia payments are reimbursable only as they are paid. Dependent care Flexible spending account: The dependent care flexible spending account (DCFSA) enables Account Information you to pay for out-of-pocket, work-related dependent daycare Participants may call NBS and talk to a representative during our costs. Please see the Summary Plan Description for the regular business hours, Monday-Friday, 7 a.m. to 7 p.m. Central definition of an eligible dependent. The law places limits on the Time. Participants can also obtain account information using the amount of money that can be paid to you in a calendar year. Automated Voice Response Unit, 24 hours a day, 7 days a week Generally, your reimbursement may not exceed the lesser of: at (385) 988-6423 or toll free at (800) 274-0503. For immediate (a) $5,000 (if you are married filing a joint return or you are access to your account information at any time, log on to our head of a household) or $2,500 (if you are married filing website at my.nbsbenefits.com or download the NBS Mobile separate returns); (b) your taxable compensation; (c) your App. spouse's actual or deemed earned income. Also, in order to have the reimbursements made to you and be What can I save with an FSA? excluded from your income, you must provide a statement from FSA No FSA the service provider including the name, address and, in most Annual taxable income $24,000 $24,000 cases, the taxpayer identification number of the service provider as well as the amount of such expense and proof that Health FSA $1,500 $0 the expense has been incurred. Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you Taxable income after FSA $21,000 $24,000 want and how much contributions should go toward each Income taxes -$6,300 -$7,200 benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered After-tax income $14,700 $16,800 benefit or expense during the plan year. $0 -$3,000 Generally, you cannot change the elections you have made after After-tax health and welfare expenses Take-home pay $14,700 $13,800 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you You saved $900 $0 have a "change in status". Please refer to your Summary Plan Description for a change in status listing.
Plan Highlights Flexible Spending Plans
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FSA (Flexible Spending Account) NBS Mobile App When you're on the go, save time and hassle with the NBS Mobile App. Submit claims, check your balances, view transactions, and submit documentation using your device's camera.
Easy and convenient •
•
Designed to work just as other iOS and Android apps which makes it easy to learn and use. Shares user authentication with the NBS portal. Registered users can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.
It's secure •
No sensitive account information is ever stored on your mobile device and secure encryption is used to protect all transmissions.
Mobile app features The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account. • View account balances • View claims • View reimbursement history • Submit claims • Submit documentation using your device's camera • Pay providers • Setup a variety of SMS alerts • Edit your personal information • View contribution details • View plan information • View calendar deadlines • Contact a service representative • View Benefits Card information
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FSA (Flexible Spending Account) Sample Expenses Medical expenses • • • • • • • • • • •
Acupuncture Addiction programs Adoption (medical expenses for baby birth) Alternative healer fees Ambulance Body scans Breast pumps Care for mentally handicapped Chiropractor Copayments Crutches
Dental expenses • • • • • • • •
Artificial teeth Copayments Deductible Dental work Dentures Orthodontia expenses Preventative care at dentist office Bridges, crowns, etc.
Vision expenses • • • • • • • •
Braille - books & magazines Contact lenses Contact lens solutions Eye exams Eye glasses Laser surgery Office fees Guide dog and upkeep/other animal aid
Diabetes (insulin, glucose monitor) Eye patches Fertility treatment First aid (i.e. bandages, gauze) Hearing aids & batteries Hypnosis (for treatment of illness) Incontinence products (i.e. Depends, Serene) Joint support bandages and hosiery Lab fees Monitoring device (blood pressure, cholesterol)
• • • • • • • • • •
Physical exams Pregnancy tests Prescription drugs Psychiatrist/psychologist (for mental illness) Physical therapy Speech therapy Vaccinations Vaporizers or humidifiers Weight loss program fees (if prescribed by physician) Wheelchair
• • • • • • • • • •
Items that generally do not qualify for reimbursement • • • • • • • • • • • •
• • •
Personal hygiene (deodorant, soap, body powder, sanitary products) Addiction products Allergy relief (oral meds, nasal spray) Antacids and heartburn relief Anti-itch and hydrocortisone creams Athlete's foot treatment Arthritis pain relieving creams Cold medicines (i.e. syrups, drops, tablets) Cosmetic surgery Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil) Counseling (i.e. marriage/family) Dental care - routine (i.e. toothpaste, toothbrushes, dental floss, anti-bacterial mouthwashes, fluoride rinses, teeth whitening/ bleaching) Exercise equipment Fever & pain reducers (i.e. Aspirin, Tylenol) Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss
• • • • • • • •
• • • • • • • •
products) Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (i.e. oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e. Pepto- Bismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppressant
These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition).
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First Time Login
NBS Web Portal How Do I Access My Online Account? Registering for and logging into your account online is easy. Just follow the instructions below.
1
Get to the website Using your Internet browser, navigate to: http://my.nbsbenefits.com Click “Register” in one of the two locations on the home page. (Highlighted in red below.)
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2
Complete the required fields of the registration form Username and password Personal information - name and email address Employee ID: Please enter your Social Security Number Employer ID OR NBS Benefits Card Number. Employer ID is a 9 digit code given to you in your welcome email from NBS, or may be obtained through your employer or by contacting NBS at (855) 399-3035 Accept the Terms of Use After completing all required fields, click “Register”
If you have questions, please call
(800) 274-0503
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THE HARTFORD YOUR BENEFITS PACKAGE
Hospital Indemnity
About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.
The median hospital costs per stay have steadily grown to over $10,000.
$8,800
9,600
10,400
2003
2008
2012
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 72 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Hospital Indemnity Plan GROUP VOLUNTARY HOSPITAL INDEMNITY INSURANCE BENEFIT HIGHLIGHTS Hospital indemnity (HI) insurance pays a cash benefit if you or an insured dependent (spouse or child) are confined in a hospital for a covered illness or injury. Even with the best primary health insurance plan, out-of-pocket costs from a hospital stay can add up. The benefits are paid in lump sum amounts to you, and can help offset expenses that primary health insurance doesn’t cover (like deductibles, co-insurance amounts or co- pays), or benefits can be used for any non-medical expenses (like housing costs, groceries, car expenses, etc.). To learn more about Hospital Indemnity insurance, visit thehartford.com/employeebenefits
COVERAGE INFORMATION Benefit amounts are based on the plan in effect for you or an insured dependent at the time the covered event occurs. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s).
A 4-day stay in the hospital could cost around $10,000.1
PLAN INFORMATION Coverage Type
On and off-job (24 hour)
Covered Events
Illness and injury
HSA Compatible
Yes
BENEFITS HOSPITAL CARE2 First Day Hospital Confinement
Up to 1 day per year
$1,000
Daily Hospital Confinement (Day 2+)
Up to 20 days per year
$100
Daily ICU Confinement (Day 1+)
Up to 20 days per year
$200
VALUE ADDED SERVICES
Ability Assist® EAP4 – 24/7/365 access to help for financial, legal or emotional issues 5
HealthChampionSM – Administrative & clinical support following serious illness or injury
ASKED AND ANSWERED IS THIS COVERAGE HSA COMPATIBLE? If you (or any dependent(s)) currently participate in a Health Saving Account (HSA) or if you plan to do so in the future, you should be aware that the IRS limits the types of supplemental insurance you may have in addition to a HSA, while still maintaining the tax- exempt status of the HSA. This plan design was designed to be compatible with Health Savings Accounts (HSAs). However, if you have or plan to open an HSA, please consult your tax and legal advisors to determine which supplemental benefits may be purchased by employees with an HSA.
Included Included
PREMIUMS The amounts shown are Monthly amounts (12 payments/deductions per year):3 Coverage Tier Employee Only $13.73 ($0.45 per day) Employee & Spouse $24.57 ($0.81 per day) Employee & Child(ren) $26.26 ($0.86 per day) Employee & Family $39.18 ($1.29 per day)
WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 20 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26. AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured. HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided above. You may elect insurance for you only, or for you and your dependent(s), by choosing the applicable coverage tier. Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, within 60 days of the date you have a change in family status, or within 60 days of the completion of any eligibility waiting period established by your employer. 73
Hospital Indemnity Plan WHEN DOES THIS INSURANCE BEGIN? Subject to any eligibility waiting period established by your employer, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility). WHEN DOES THIS INSURANCE END? This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.
1. 2. 3. 4.
5.
“Hospital Adjusted Expenses per Inpatient Day.” Kaiser Family Foundation. 2015. Web. 2 Mar. 2017. For Hospital Care benefits, when an insured is eligible for more than one benefit in a single day, only the highest benefit will be paid. Rates and/or benefits may be changed. AbilityAssist® services are offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Ability Assist is a registered trademark of The Hartford. Services may not be available in all states. Visit https://www.thehartford.com/ employee-benefits/value-added-services for more information. HealthChampion℠ services are provided through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford doesn’t provide basic hospital, basic medical, or major medical insurance. HealthChampion specialists are only available during business hours. Inquiries outside of this timeframe can either request a call-back the next day or schedule an appointment. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Health Champion is a service mark of ComPsych. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information.
Prepare. Protect. Prevail. With The Hartford. ® 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. 5962h NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details including the provisions, terms, conditions, limitations and exclusions are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Hospital does not include: convalescent homes, or convalescent, rest or nursing facilities; facilities affording primarily custodial, educational or rehabilitory care; or facilities primarily for care of the aged/elderly, persons with substance abuse issues/ disorders or mental/nervous disorders. Confinement means the assignment to a bed in a medical facility for a period of at least 20 consecutive hours. Required hours may vary by state. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Hospital Income Plan Form Series includes GBD-2800, GBD-2900, or state equivalent.
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75
LINCOLN FINANCIAL GROUP
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 76 details on covered expenses,Frisco limitations and exclusions included in the summary plan description located on the ISD Benefits Website:are www.mybenefitshub.com/friscoisd Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Dental– High PPO Full-Time Associates, Mid-Management and Executives of Life School of Dallas
Benefits At-A-Glance Dental Insurance High Option The Lincoln DentalConnect® PPO Plan: • Covers many preventive, basic, and major dental care services • Also covers orthodontic treatment for children • Features group coverage for Life School of Dallas employees • Allows you to choose any dentist you wish, though you can lower your outof-pocket costs by selecting a contracting dentist • Does not make you and your loved ones wait six months between routine cleanings
Contracting Dentists Non-Contracting Dentists Individual: $50 Individual: $50 Plan Year Deductible Family: $150 Family: $150 Waived for: Preventive Waived for: Preventive Deductibles are combined for basic and major Contracting Dentists’ services. Deductibles are combined for basic and major Non-Contracting Dentists’ services. Annual Maximum $2,000 $2,000 Annual Maximums are combined for preventive, basic, and major services. Lifetime Orthodontic Max $1,000 $1,000 Orthodontic Coverage is available for dependent children. There are no benefit waiting periods for any Waiting Period service types Visit LincolnFinancial.com/FindADentist You can search by: • Location • Dentist name or office name • Distance you are willing to travel • Specialty, language and more Your search will automatically provide up to 100 dentists that most closely match your criteria. If your search does not locate the dentist you prefer, you can nominate one—just click the Nominate a Dentist link and complete the online form.
Preventive Services Routine oral exams Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays (including periapical films) Routine cleanings Fluoride treatments Space maintainers for children Sealants Problem focused exams Consultations Basic Services Palliative treatment (including emergency relief of dental pain) Injections of antibiotics and other therapeutic medications Fillings Simple extractions Surgical extractions Oral surgery Biopsy and examination of oral tissue (including brush biopsy) General anesthesia and I.V. sedation Prosthetic repair and recementation services Endodontics (including root canal treatment) Periodontal maintenance procedures Non-surgical periodontal therapy Periodontal surgery Denture reline and rebase services Occlusal guard Major Services Prefabricated stainless steel and resin crowns Bridges Full and partial dentures Crowns, inlays, onlays and related services Implants & implant related services
Contracting Dentists
Non-Contracting Dentists
100% No Deductible
100% No Deductible
Contracting Dentists
Non-Contracting Dentists
80% After Deductible
80% After Deductible
Contracting Dentists
Non-Contracting Dentists
50% After Deductible
50% After Deductible 77
Dental– High PPO Orthodontics Orthodontic exams X-rays Extractions Study models Appliances To find a contracting dentist near you, visit www.LincolnFinancial.com/FindADentist.
• • • • •
Find a network dentist near you in minutes Have an ID card on your phone Customize the app to get details of your plan Find out how much your plan covers for checkups and other services Keep track of your claims
Lincoln DentalConnect® Online Health Center • • • •
Determine the average cost of a dental procedure Have your questions answered by a licensed dentist Learn all about dental health for children, from baby’s first tooth to dental emergencies Evaluate your risk for oral cancer, periodontal disease and tooth decay
Covered Family Members When you choose coverage for yourself, you can also provide coverage for: • Your spouse. • Dependent children, up to age 26.
Benefit Exclusions Like any coverage, this dental coverage does have some exclusions. • The plan does not cover services started before coverage begins or after it ends. Benefits are limited to appropriate and necessary procedures listed in the summary plan description. Benefits are not payable for duplication of services. Covered expenses will not exceed the summary plan description’s usual and customary allowances. • Plan benefits are not payable for a condition that is covered under Workers’ Compensation or a similar law; that occurs during the course of employment or military service or involvement in an illegal occupation,
Non-Contracting Dentists
50%
50%
… you pay a deductible (if applicable), …you pay a deductible (if then 50% of the usual and customary applicable), then 50% of the fee, which is the maximum expense remaining discounted fee for PPO covered by the plan. You are members. This is known as a PPO responsible for the difference contracted fee. between the usual and customary fee and the dentist’s billed charge.
This plan lets you choose any dentist you wish. However, your outof-pocket costs are likely to be lower when you choose a contracting dentist. For example, if you need a crown…
With the Lincoln Dental Mobile App
Contracting Dentists
felony, or riot; or that results from a self-inflicted injury. The plan does not cover an orthodontia treatment plan started before coverage begins unless the member was receiving orthodontia benefits from the employer’s previous group dental summary plan description. In this case, Lincoln Financial will continue orthodontia benefits until the combined benefit paid by both policies is equal to this summary plan description’s lifetime orthodontia maximum. Plan benefits are not payable if the orthodontic appliance was installed after the age of 19. • In certain situations, there may be more than one method of treating a dental condition. This summary plan description includes an alternative benefits provision that may reduce benefits to the lowest- cost, generally effective, and necessary form of treatment. • Certain conditions, such as age and frequency limitations, may impact your coverage. See the summary plan description for details. • This plan includes continuation of coverage for employees with dental coverage from a previous employer. The member is required to complete the Continuity of Coverage form located on www.lfg.com. The form must be provided to us prior to the effective date to be eligible for continuation of coverage. A complete list of benefit exclusions is included in the summary plan description. •
Questions? Call 800-423-2765 and mention Group ID: LIFESCHDAL. This is not intended as a complete description of the coverage offered. Controlling provisions are provided in the summary plan description, and this summary does not modify coverage. A summary plan description will be made available to you that describes the benefits in greater detail. Refer to your summary plan description for your maximum benefit amounts. Lincoln DentalConnect® health center Web content is provided by go2dental.com, Santa Clara, CA. Go2dental.com is not a Lincoln Financial Group® company. Coverage is subject to actual summary plan description language. Each independent company is solely responsible for its own obligations. The Lincoln National Life Insurance Company (Fort Wayne, IN), does not conduct business in New York, nor is it licensed to do so. In New York, business is conducted by Lincoln Life & Annuity Company of New York (Syracuse NY). Both are Lincoln Financial Group Companies. ©2020 Lincoln National Corporation LCN-2012491-013118 R 1.0 – Group ID: LIFESCHDAL
Dental Rate Here’s how little you pay with group rates. As a Life School of Dallas employee, you can take advantage of this dental coverage for less than $.74 a day. Plus, you can add loved ones to the plan for just a little more. Your estimated cost is itemized below. Dental PPO High Employee Emp + Sp Emp + Ch Emp + Fam
78
Monthly Premium Monthly Contribution Total Premium Paid by Life School $37.90 $15.23 $77.88 $15.23 $93.78 $15.23 $116.81 $15.23
Monthly EE Cost Paid by Employee $22.67 $62.65 $78.55 $101.58
Bi-Weekly Contribution Paid by Life School $7.62 $7.62 $7.62 $7.62
Bi-Weekly EE Cost Paid by Employee $11.34 $31.33 $39.28 $50.79
Dental– Low PPO Full-Time Associates, Mid-Management and Executives of Life School of Dallas
Benefits At-A-Glance Dental Insurance Low Option The Lincoln DentalConnect® PPO Plan: • Covers many preventive, basic, and major dental care services • Features group coverage for Life School of Dallas employees • Allows you to choose any dentist you wish, though you can lower your out-of -pocket costs by selecting a contracting dentist • Does not make you and your loved ones wait six months between routine cleanings
Contracting Dentists Non-Contracting Dentists Individual: $100 Individual: $100 Plan Year Deductible Family: $300 Family: $300 Waived for: Preventive Waived for: Preventive Deductibles are combined for basic and major Contracting Dentists’ services. Deductibles are combined for basic and major Non-Contracting Dentists’ services. Annual Maximum $750 $750 Annual Maximums are combined for preventive, basic, and major services. There are no benefit waiting periods for any Waiting Period service types Visit LincolnFinancial.com/FindADentist You can search by: • Location • Dentist name or office name • Distance you are willing to travel • Specialty, language and more Your search will automatically provide up to 100 dentists that most closely match your criteria. If your search does not locate the dentist you prefer, you can nominate one—just click the Nominate a Dentist link and complete the online form.
Preventive Services Routine oral exams Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays (including periapical films) Routine cleanings Fluoride treatments Space maintainers for children Sealants Problem focused exams Consultations Basic Services Palliative treatment (including emergency relief of dental pain) Injections of antibiotics and other therapeutic medications Fillings Biopsy and examination of oral tissue (including brush biopsy) Prosthetic repair and recementation services Denture reline and rebase services Major Services Prefabricated stainless steel and resin crowns Simple extractions Surgical extractions Oral surgery General anesthesia and I.V. sedation Endodontics (including root canal treatment) Periodontal maintenance procedures Non-surgical periodontal therapy Periodontal surgery Bridges Full and partial dentures Crowns, inlays, onlays and related services Implants & implant related services Occlusal guard
Contracting Dentists
Non-Contracting Dentists
80% No Deductible
80% No Deductible
Contracting Dentists
Non-Contracting Dentists
80% After Deductible
80% After Deductible
Contracting Dentists
Non-Contracting Dentists
50% After Deductible
50% After Deductible
79
Dental– Low PPO Orthodontics
Contracting Dentists
To find a contracting dentist near you, visit www.LincolnFinancial.com/FindADentist. This plan lets you choose any dentist you wish. However, your outof-pocket costs are likely to be lower when you choose a contracting dentist. For example, if you need a crown…
With the Lincoln Dental Mobile App • • • • •
Find a network dentist near you in minutes Have an ID card on your phone Customize the app to get details of your plan Find out how much your plan covers for checkups and other services Keep track of your claims
Lincoln DentalConnect® Online Health Center • • • •
Determine the average cost of a dental procedure Have your questions answered by a licensed dentist Learn all about dental health for children, from baby’s first tooth to dental emergencies Evaluate your risk for oral cancer, periodontal disease and tooth decay
Covered Family Members When you choose coverage for yourself, you can also provide coverage for: • Your spouse. • Dependent children, up to age 26.
Benefit Exclusions Like any coverage, this dental coverage does have some exclusions. • The plan does not cover services started before coverage begins or after it ends. Benefits are limited to appropriate and necessary procedures listed in the summary plan description. Benefits are not payable for duplication of services. Covered expenses will not exceed the summary plan description’s usual and customary allowances. • Plan benefits are not payable for a condition that is covered under Workers’ Compensation or a similar law; that occurs during the course of
Non-Contracting Dentists
… you pay a deductible (if applicable), then 50% of the usual …you pay a deductible (if and customary fee, which is the applicable), then 50% of the maximum expense covered by remaining discounted fee for the plan. You are responsible for PPO members. This is known the difference between the usual as a PPO contracted fee. and customary fee and the dentist’s billed charge. employment or military service or involvement in an illegal occupation, felony, or riot; or that results from a self-inflicted injury. • In certain situations, there may be more than one method of treating a dental condition. This summary plan description includes an alternative benefits provision that may reduce benefits to the lowest- cost, generally effective, and necessary form of treatment. • Certain conditions, such as age and frequency limitations, may impact your coverage. See the summary plan description for details. • This plan includes continuation of coverage for employees with dental coverage from a previous employer. The member is required to complete the Continuity of Coverage form located on www.lfg.com. The form must be provided to us prior to the effective date to be eligible for continuation of coverage. A complete list of benefit exclusions is included in the summary plan description. Questions? Call 800-423-2765 and mention Group ID: LIFESCHDAL. This is not intended as a complete description of the coverage offered. Controlling provisions are provided in the summary plan description, and this summary does not modify coverage. A summary plan description will be made available to you that describes the benefits in greater detail. Refer to your summary plan description for your maximum benefit amounts. Lincoln DentalConnect® health center Web content is provided by go2dental.com, Santa Clara, CA. Go2dental.com is not a Lincoln Financial Group® company. Coverage is subject to actual summary plan description language. Each independent company is solely responsible for its own obligations. The Lincoln National Life Insurance Company (Fort Wayne, IN), does not conduct business in New York, nor is it licensed to do so. In New York, business is conducted by Lincoln Life & Annuity Company of New York (Syracuse NY). Both are Lincoln Financial Group Companies. ©2020 Lincoln National Corporation LCN-2012491-013118 R 1.0 – Group ID: LIFESCHDAL
Dental Rate Here’s how little you pay with group rates. As a Life School of Dallas employee, you can take advantage of this dental coverage for less than $.74 a day. Plus, you can add loved ones to the plan for just a little more. Your estimated cost is itemized below. Dental PPO Low Employee Emp + Sp Emp + Ch Emp + Fam
80
Monthly Premium Monthly Contribution Total Premium Paid by Life School $15.23 $15.23 $30.45 $15.23 $35.96 $15.23 $55.86 $15.23
Monthly EE Cost Paid by Employee $0 $15.22 $20.73 $40.63
Bi-Weekly Contribution Paid by Life School $7.62 $7.62 $7.62 $7.62
Bi-Weekly EE Cost Paid by Employee $0 $7.61 $10.37 $20.32
Dental– DHMO Now Available to Full-Time Employees of Life School of Dallas: Dental insurance with affordable group rates
Simplify your dental care and save. Trips to the dentist are a little less scary when you know how much you’ll pay ahead of time. And easier, too, with no claim forms or deductibles.
The Lincoln DentalConnect® DHMO Plan: • • • • •
Covers most preventive and diagnostic care services at no charge Also covers a wide variety of specialty services - lowering your out-of-pocket costs with no deductibles or maximums Features group rates for Life School of Dallas employees Lets you choose a participating dentist from a regional network Saves you time and hassle with no waiting periods and no claim forms
Here’s how this important coverage works. •
• • • •
You choose your primary-care dentist when you enroll. To find a participating dentist, visit http://ldc.lfg.com, select Find a Dentist, and choose the Texas LDC Plan 5 network. (You can also print your dental ID card from this site once your coverage begins.) This dental plan offers a detailed list of covered procedures, each with a dollar copayment (see the Summary of Benefits for details). You pay for services provided during your visit. Emergency care away from home is covered up to a set dollar limit. You can change your primary-care dentist at any time by calling the customer service number listed on your dental ID card. A complete Summary of Benefits is included on the next few pages.
Here’s how little you pay with group rates. As a Life School of Dallas employee, you can take advantage of this dental insurance plan for less than $0.33 a day. Plus, you can add loved ones to the plan for just a little more. Dental DHMO Employee Emp + Sp Emp + Ch Emp + Fam
Monthly Premium Monthly Contribution Total Premium Paid by Life School $9.86 $9.86 $19.21 $9.86 $20.78 $9.86 $30.04 $9.86
Monthly EE Cost Paid by Employee $0 $9.35 $10.92 $20.18
Bi-Weekly Contribution Paid by Life School $4.93 $4.93 $4.93 $4.93
Bi-Weekly EE Cost Paid by Employee $0 $4.68 $5.46 $10.09
No money is due at enrollment. Your premium simply comes out of your paycheck.
Lincoln DentalConnect® DHMO (policy series TX-EOC 08 2010) is underwritten in Texas by National Pacific Dental, Inc., Houston, TX. National Pacific Dental is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations. 81
SUPERIOR VISION
Vision
YOUR BENEFITS PACKAGE
About this Benefit Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.
75% of U.S. residents between age 25 and 64 require some sort of vision correction.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 82 details on covered expenses,Frisco limitations and exclusions included in the summary plan description located on the ISD Benefits Website:are www.mybenefitshub.com/friscoisd Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Vision Benefits Exam (ophthalmologist) Exam (optometrist) Frames
In-Network
Out-of-Network
Covered in full
Up to $42 retail
EE Only
$6.90
Covered in full
Up to $37 retail
EE + Spouse
$13.12
$150 retail allowance
Up to $60 retail
EE + Child(ren)
$13.75
EE + Family
$21.15
Contact Lens Fitting Covered in full Not covered (standard2) Contact Lens Fitting $50 retail allowance Not covered (specialty2) 2 Contact Lenses $130 retail allowance Up to $100 retail
Monthly Premiums
Co-Pays Exam
$10 1
Materials Contact fittings
$25 $25
(standard & specialty)
Lenses (standard) per pair Single Vision
Covered in full
Up to $26 retail
Bifocal
Covered in full
Up to $34 retail
Trifocal Progressive lens upgrade Factory Scratch Coat
Covered in full
Up to $50 retail
See description3
Up to $50 retail
Covered in Full
Not Covered
Services/Frequency Exam
12 months
Frame
24 months
Contact Lens Fitting
12 months
Lenses
12 months
Contact Lenses
12 months
(Based on date of service) Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 1. Materials co-pay applies to lenses and frames only, not contact lenses 2. Standard Contact Lens Fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty Contact Lens Fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses. 3. Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4. Contact lenses are in lieu of eyeglass lenses and frames benefit
Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary.
Discounts on Covered Materials Frames: Lens options: Progressives:
20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options Specialty Contact Lens Fit: 10% off retail, then apply allowance The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) plastic lenses. Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal Ultraviolet coat $15 $15 Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50 Polycarbonate $40 20% off retail High index 1.6 $55 20% off retail Photochromics $80 20% off retail 5
SuperiorVision.com Customer Service 800.507.3800 Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail Retinal Imaging: $39 max out-of-pocket
Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 10%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance. All allowances are retail; member is responsible for any amount over the allowance, minus available discounts. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.
Discounts and maximums may vary by lens type. Please check with your provider.
Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 800.507.3800 SuperiorVision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0518-BSv2/TX
83
UNUM
Short Term Disability
YOUR BENEFITS PACKAGE
About this Benefit Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance will replace a portion of your income in the event that you become physically unable to work. Short term disability coverage provides benefits when you are unable to work for a short period of time due to a covered sickness or injury.
60% of Americans do not have a “rainy day” fund to cover three months of unanticipated financial emergencies.
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 84 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Short Term Disability Life School of Dallas Voluntary Short Term Disability Insurance Plan Highlights Policy Number 419941 Who is eligible?
You are eligible for Short Term Disability coverage if you are an active employee in the United States working a minimum of 30 hours per week.
What is my weekly benefit amount?
You can elect to purchase a benefit of 60% of your weekly earnings to a maximum of $500 per week.
How long do I have to wait to receive The elimination period is the length of time you must be continuously disabled before benefits? you can receive benefits. If your disability is the result of a covered injury or sickness, you could begin receiving benefits after 7 days. When would I be considered disabled?
You are disabled when Unum determines that, due to sickness or injury: • You are limited from performing the material and substantial duties of your regular occupation;* and • You have a 20% or more loss in weekly earnings due to the same sickness or injury. *Unless the policy specifies otherwise, as part of the disability claims evaluation process, Unum will evaluate your occupation based on how it is normally performed in the national economy, not how work is performed for a specific employer, at a specific location, or in a specific region.
How long will my benefits last?
As long as you continue to meet the definition of disability, you may receive benefits for 12 weeks.
How much does it cost?
Employee Age <25 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 +
Rate per $10 weekly benefit $0.972 $1.048 $0.886 $0.680 $0.659 $0.583 $0.724 $0.961 $1.188 $1.264 $1.264
Here’s how to calculate your per-paycheck costs: ____________ ÷ 52 = ___________ Annual salary Weekly salary
X __60%___= _____________ Benefit % Weekly benefit
____________ ÷ 10 = ___________ Weekly benefit
X _________= ___________ Your rate Monthly cost
____________ X 12 = ___________ Monthly cost Annual cost
÷ _________= _______________ # paychecks Cost per paycheck
If your annual salary exceeds $43,333 use $43,333 as your annual salary for this calculation. Final costs may vary due to rounding. 85
Short Term Disability What if I am out of work when the coverage goes into effect?
Insurance will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that coverage would otherwise become effective.
Can my benefit be reduced?
Your disability benefit may be reduced by deductible sources of income and any earnings you have while disabled. Deductible sources of income may include such items as disability income or other amounts you receive or are entitled to receive under: workers’ compensation or similar occupational benefit laws; state compulsory benefit laws; automobile liability and no fault insurance; legal judgments and settlements; certain retirement plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs.
Do I have to take a health exam to get coverage?
You may receive coverage without answering any medical questions or providing evidence of insurability if you apply for coverage within 31 days after your eligibility date. If you apply more than 31 days after your eligibility date, your coverage will be medically underwritten. You may also have to provide information about routine, planned, unplanned or ongoing medical care or consultation. This review may result in coverage being declined.
Can I receive rehabilitation and return-to If you are deemed eligible and are participating in the program, Unum will pay an additional -work services? benefit of 10% of your gross disability payment, to a maximum of $250 per week. Are my benefits taxed?
It depends on how your premium was taxed during the plan year in which you become disabled. If you paid the premium for the plan year with post-tax dollars, your benefits will not be taxed. However, if you paid the premium for the plan year with pre-tax dollars, your benefits will be taxed. If you paid the premium for the plan year with a combination of preand post-tax dollars, then a portion of your benefits will be taxed.
What is not covered?
Benefits would not be paid for disabilities caused by, contributed to by, or resulting from: •War, declared or undeclared or any act of war; •Active participation in a riot; •Intentionally self-inflicted injuries; •Loss of professional license, occupational license or certification; •Commission of a crime for which you have been convicted; •Any period of disability during which you are incarcerated; •Any occupational injury or sickness (this will not apply to a partner or sole proprietor who cannot be covered by law under workers’ compensation or any similar law); •Pre-existing conditions (see definition).
When does my coverage end?
Your coverage under the policy ends on the earliest of: •The date the policy or plan is cancelled; •The date you no longer are in an eligible group; •The date your eligible group is no longer covered; •The last day of the period for which you made any required contributions; •The last day you are in active employment except as provided under the covered layoff or leave of absence provision.
How can I apply for coverage?
Please see your plan administrator for further information on these provisions. Please see your plan administrator
You are considered in active employment, if on the day you apply for coverage, you are being paid regularly by your employer for the required minimum hours each week and you are performing the material and substantial duties of your regular occupation. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al, or contact your Unum representative. Underwritten by Unum Life Insurance Company of America, Portland, Maine © 2017 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. EN-1780 (1-17) FOR EMPLOYEES
86
87
UNUM YOUR BENEFITS PACKAGE
Long Term Disability
About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.
34.6 months is the duration of the average disability claim.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 88 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Long Term Disability Life School of Dallas Long Term Disability Insurance Plan Highlights Policy Number 419942 Who is eligible?
You are eligible for Long Term Disability (LTD) coverage if you are an active employee in the United States working a minimum of 30 hours per week.
What is my monthly benefit amount?
You can elect to purchase a benefit of 60% of your monthly earnings to a maximum of $9,500. The elimination period is the length of time you must be continuously disabled before you can receive benefits. You could begin receiving LTD benefits if, after 90 days of disability, you are still disabled (as described in the definition of disability).
How long do I have to wait to receive benefits?
If you return to work while satisfying the elimination period and are no longer disabled, you may satisfy the elimination period within the accumulation period – you don’t have to be continuously disabled through the elimination period, if you are satisfying the elimination period under this provision. If you don’t satisfy the elimination period within the accumulation period, a new period of disability will begin. Accumulation Period is the period of time from the date the disability begins during which you must satisfy the elimination period. The accumulation period is two times your elimination period.
How long will my benefits last?
When is my coverage effective?
During your elimination period, you will be considered disabled if you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury, and you are under the regular care of a physician. You are not required to have a 20% or more earnings loss to be considered disabled during the elimination period due to the same sickness or injury. The duration of your benefit payments is based on your age when your disability occurs. Your LTD benefits are payable for the period during which you continue to meet the definition of disability. If your disability occurs before age 62, benefits could be payable up to the Social Security Normal Retirement Age. If your disability occurs at or after age 62, your benefits would be paid according to the benefit duration schedule. Please see your plan administrator for your effective date.
What if I am out of work Insurance will be delayed if you are not in active employment because of an injury, sickness, when the coverage goes into temporary layoff, or leave of absence on the date that insurance would otherwise become effective. effect? What is my maximum monthly benefit amount?
Can my benefit be reduced?
Your total monthly benefit (including all benefits provided under this plan) will not exceed 100% of your monthly earnings, unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, your total monthly benefit (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment). Your disability benefit may be reduced by deductible sources of income and any earnings you have while disabled. Deductible sources of income may include such items as disability income or other amounts you receive or are entitled to receive under: workers’ compensation or similar occupational benefit laws; state compulsory benefit laws; automobile liability and no fault insurance; legal judgments and settlements; certain retirement plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs. 89
Long Term Disability
When would I be considered disabled?
What does “gainful occupation” mean? Can I receive rehabilitation and return-to-work services? What other services are available?
What else is included with this policy?
Does this plan include help with work-life balance?
What happens if I die while receiving disability benefits?
You are disabled when Unum determines that due to your sickness or injury: • you are unable to perform the material and substantial duties of your regular occupation; and • you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury: • You are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. Gainful occupation means an occupation that is expected to provide, within 12 months of your return to work, an income that exceeds: 80% of your indexed monthly earnings, if you are working; or 60% of your indexed monthly earnings, if you are not working. If you are deemed eligible and are participating in the program, Unum will pay an additional benefit of 10% of your gross disability payment to a maximum of $1,000 per month. If you are disabled, participating in the rehabilitation and return-to-work assistance program, and have dependent care expenses, you may also receive the dependent care expense benefit — $350 per dependent per month, to a monthly maximum of $1,000 for all eligible dependents combined. Worldwide emergency travel assistance is included with this long term disability plan. Emergency travel assistance is available to you, your spouse* and your dependent children when you travel to any foreign country, including Canada or Mexico. It is also available anywhere in the United States when you travel just 100 or more miles from home. * A spouse traveling on business for his or her employer is not covered by the program. Yes. Our work-life balance employee assistance program (EAP) provides professional advice for a wide range of personal and work-related issues. The service is available to you and your family members 24 hours a day, 365 days a year. It provides resources to help you find solutions to everyday issues — such as financing a car or selecting child care — as well as more serious problems, such as alcohol or drug addiction, divorce or relationship problems. There is no additional charge for using the program, and you do not have to have filed a disability claim or be receiving benefits to use the program. Your eligible survivor will receive a lump-sum benefit equal to three months of your gross disability payment if, on the date of your death, you had been disabled for 180 or more consecutive days, and you were receiving or were entitled to receive payments under the plan. You may request this benefit early if you have been diagnosed with a terminal illness resulting in a life expectancy of less than 12 months, and you are receiving monthly payments. If you choose to receive this benefit, no survivor benefit will be payable to your eligible survivor upon your death.
Are my benefits taxed?
Any benefit that is paid by your employer is generally taxable.
Does my plan cover mental and nervous conditions?
Yes. Depending on your plan, the lifetime cumulative maximum benefit period for all disabilities due to mental illness and disabilities based primarily on self-reported symptoms is 24 months. Only 24 months of benefits will be paid for any combination of such disabilities — even if the disabilities are not continuous and/or are not related. Payments may only continue beyond 24 months if you are confined to a hospital or institution as a result of the disability.
What is not covered?
Benefits would not be paid for disabilities caused by, contributed to by, or resulting from: • Intentionally self-inflicted injuries; • Active participation in a riot; • War, declared or undeclared, or any act of war; • Commission of a crime for which you have been convicted; • Loss of professional license, occupational license or certification; or • Pre-existing conditions (see pre-existing condition section) The loss of a professional or occupational license does not, in itself, constitute disability. Unum will not pay a benefit for any period of disability during which you are incarcerated.
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Long Term Disability What is considered a preexisting condition?
When does my coverage end?
You have a pre-existing condition if: • You received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and • The disability begins in the first 12 months after your effective date of coverage. Your coverage under the policy ends on the earliest of the following: • The date the policy or plan is cancelled; • The date you no longer are in an eligible group; • The date your eligible group is no longer covered; • The last day of the period for which you made any required contributions; • The last day you are in active employment except as provided under the covered layoff or leave of absence provision. Please see your plan administrator for further information on these provisions. Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.
You are considered in active employment, if on the day you apply for coverage, you are being paid regularly by your employer for the required minimum hours each week and you are performing the material and substantial duties of your regular occupation. The work-life balance employee assistance program, provided by HealthAdvocate, is available with select Unum insurance offerings. Terms and availability of service are subject to change. Service provider does not provide legal advice; please consult your attorney for guidance. Services are not valid after coverage terminates. Please contact your Unum representative for details. Worldwide emergency travel assistance services, provided by Assist America, Inc., are available with select Unum insurance offerings. Terms and availability of service are subject to change and prior notification requirements. Services are not valid after coverage terminates. Please contact your Unum representative for details. Underwritten by Unum Life Insurance Company of America, Portland, Maine This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al, or contact your Unum representative. © 2018 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. EN-1777 (6-18) FOR EMPLOYEES
91
ONEAMERICA
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 92 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Life and AD&D What you need to know: Are you eligible? Benefits are available to employees who are actively at work on the effective date of coverage and working the minimum number of hours per week stated in the contract. Your premiums and benefits may vary. Actual premiums and benefit amounts will be calculated by OneAmerica and may change upon reaching certain ages, according to contract terms, and are subject to change. Volumes and benefit amounts shown may be subject to reductions due to age. Enroll timely for guaranteed issue coverage. You may be eligible for coverage without having to answer any health questions if you enroll during the initial enrollment period when benefits are first offered by OneAmerica®, or if you enroll as a newly hired employee within 31 days after any applicable waiting period. Enrolling later requires approval. If you decline coverage now, you will lose your only chance to apply for group insurance coverage without having to first undergo medical underwriting. If you decide to enroll later, you will need to submit a Statement of Insurability form for review. OneAmerica will then decide to approve or deny your coverage based on your health history. You may not be approved for any type of coverage at a later date if you have any current or future medical conditions.
What you need to do: Carefully review the contents of this packet. Enclosed is personal information about the benefits offered to you by OneAmerica on behalf of your employer. This is your opportunity to learn more about group insurance from OneAmerica, but it is not a complete explanation of benefits. For more information, consult the contract about exclusions, limitations, reduction of benefits, and terms under which the contract may be continued in force or discontinued. Review the Notices and Limitations. Visit www.employeebenefits.aul.com to find the Notices and Limitations, G-14320 (05 Prudent) 12/28/12. Go to Forms, Policy/Employee Admin, and Notices and Limitations. Note: Products issued and underwritten by American United Life Insurance Company® (AUL), a OneAmerica company. Not available in all states or may vary by state. OneAmerica is the marketing name for the companies of OneAmerica.
THE NEED FOR LIFE INSURANCE Protecting the ones you care about most
income, and will assist your family in paying final expenses. It will also allow your loved ones to continue any future plans, such as college education or savings. Why you need it There are several reasons you need life insurance. In addition to paying for burial expenses, consider life insurance an option to pay for the mortgage, medical expenses and fund college education. If you work or have savings, then you have the income to pay these bills. However, consider what happens when your loved ones no longer have your financial support. How much is enough Figuring out how much life insurance you need is hard to decide. You want to make sure you have enough to protect your family. To help you answer this question, use the calculator to estimate your expenses to think about which bills would need income protection. Estimate your expenses below Income and possessions
Amount
Annual income Number of years until retirement Subtotal (annual income x years) Debt and final expenses Credit card(s), car payment(s), etc. Funeral and burial expenses ($7,000 is a good estimate) Subtotal (debt) Educational costs College expenses
Subtotal (education) Total needed for your life insurance
$
Typically, life insurance offered through work is less expensive than if you purchased it on your own. Consider purchasing life insurance today.
“How will my loved ones be taken care of when I’m gone?” This question isn’t something anyone wants to think about, but if someone depends on you for financial support, then life insurance is your answer. Income protection for your loved ones No matter what your current situation is: single, married, with or without children; life insurance helps replace your
93
Life and AD&D What you need to know about your Basic Life and AD&D Benefits
What you need to know about your Voluntary Term Life Benefits and AD&D Benefits
Guaranteed Issue:
Flexible Options: Employee: $10,000 to $500,000, in $10,000 increments. Spouse: $10,000 to $500,000, in $5,000 increments, not to exceed 100% of the employee’s amount.
Employee: $20,000
Accidental Death and Dismemberment (AD&D): Additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract. Additional AD&D benefits include seat belt, air bag, repatriation, child higher education, child care, paralysis/loss of use, severe burns, disappearance, Guaranteed Issue: and exposure. Employee: $200,000 Spouse: $50,000 Accelerated Life Benefit: If diagnosed with a terminal illness Child: $10,000 and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to Dependent Life Coverage: Optional dependent life coverage use for whatever you choose. is available to eligible employees. You must select employee coverage in order to cover your spouse and/or Reductions: Upon reaching certain ages, your original child(ren). benefit amount will reduce to the percentage shown in the following schedule. Accidental Death and Dismemberment (AD&D): You must 70 select Life coverage in order to select any AD&D coverage. Reduces To: 50% Additional life insurance benefits may be payable in the event of an accident which results in death or Basic Employee Life and AD&D Coverage Your Life and AD&D insurance coverage amount is $20,000. dismemberment as defined in the contract. Coverage is provided at no cost to you.
Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose. Guaranteed Increase In Benefit: You may be eligible to increase your coverage annually until you reach your maximum amount without providing evidence of insurability. Reductions: Upon reaching certain ages, your original benefit amount will reduce to the percentage shown in the following schedule. The amounts of dependent life insurance and dependent AD&D principal sum will reduce according to the employee's reduction schedule. Reduces To:
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70 50%
Life and AD&D Payroll Deduction Illustration: Monthly
Life 0-19 Life 0-19 $10,000 $.80 $20,000 $1.60 $30,000 $2.40 $40,000 $3.20 $50,000 $4.00 $80,000 $6.40 $100,000 $8.00 $130,000 $10.40 $150,000 $12.00 $200,000 $16.00
20-24 20-24 $.80 $1.60 $2.40 $3.20 $4.00 $6.40 $8.00 $10.40 $12.00 $16.00
25-29 25-29 $.80 $1.60 $2.40 $3.20 $4.00 $6.40 $8.00 $10.40 $12.00 $16.00
30-34 30-34 $1.00 $2.00 $3.00 $4.00 $5.00 $8.00 $10.00 $13.00 $15.00 $20.00
35-39 35-39 $1.10 $2.20 $3.30 $4.40 $5.50 $8.80 $11.00 $14.30 $16.50 $22.00
Employee Options 40-44 45-49 40-44 45-49 $1.30 $1.90 $2.60 $3.80 $3.90 $5.70 $5.20 $7.60 $6.50 $9.50 $10.40 $15.20 $13.00 $19.00 $16.90 $24.70 $19.50 $28.50 $26.00 $38.00
50-54 50-54 $3.00 $6.00 $9.00 $12.00 $15.00 $24.00 $30.00 $39.00 $45.00 $60.00
55-59 55-59 $4.60 $9.20 $13.80 $18.40 $23.00 $36.80 $46.00 $59.80 $69.00 $92.00
60-64 60-64 $7.10 $14.20 $21.30 $28.40 $35.50 $56.80 $71.00 $92.30 $106.50 $142.00
65-69 65-69 $12.80 $25.60 $38.40 $51.20 $64.00 $102.40 $128.00 $166.40 $192.00 $256.00
70-74 70-74 $20.60 $41.20 $61.80 $82.40 $103.00 $164.80 $206.00 $267.80 $309.00 $412.00
Life $10,000 $20,000 $30,000 $40,000 $50,000
20-24 $.80 $1.60 $2.40 $3.20 $4.00
25-29 $.80 $1.60 $2.40 $3.20 $4.00
30-34 $1.00 $2.00 $3.00 $4.00 $5.00
35-39 $1.10 $2.20 $3.30 $4.40 $5.50
Spouse Options 40-44 45-49 $1.30 $1.90 $2.60 $3.80 $3.90 $5.70 $5.20 $7.60 $6.50 $9.50
50-54 $2.78 $5.56 $8.34 $11.12 $13.90
55-59 $4.60 $9.20 $13.80 $18.40 $23.00
60-64 $7.10 $14.20 $21.30 $28.40 $35.50
65-69 $12.80 $25.60 $38.40 $51.20 $64.00
70-74 75+ $20.60 $31.40 $41.20 $62.80 $61.80 $94.20 $82.40 $125.60 $103.00 $157.00
Life Option 1:
0-19 $.80 $1.60 $2.40 $3.20 $4.00
Child(ren) 6 months to age 26 $10,000
Child Options Child(ren) live birth to 6 months $1,000
75+ 75+ $31.40 $62.80 $94.20 $125.60 $157.00 $251.20 $314.00 $408.20 $471.00 $628.00
Deduction Amount Child(ren) $3.00
Note: Employee and Spouse premiums are based on your age as of 09/01 and amount of coverage chosen. Child premiums are for all eligible children combined. G 00617024-0000-000 OneAmerica® is the marketing name for the companies of OneAmerica. Friendswood Independent School District Class: 1 Rate Effective Date: 9/1/2018
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ComPsych GuidanceResources® Program “Employee Assistance Program" this benefit is provided by your employer at no charge to the employee.
Call Your ComPsych® GuidanceResources® program anytime for confidential assistance. Call: 855.387.9727 TDD: 800.697.0353 Go online: guidanceresources.com Your company Web ID: ONEAMERICA3 Personal issues, planning for life events or simply managing daily life can affect your work, health and family. Your GuidanceResources program provides support, resources and information for personal and work-life issues. The program is companysponsored, confidential and provided at no charge to you and your dependents. This flyer explains how GuidanceResources can help you and your family deal with everyday challenges.
Confidential Counseling
Work-Life Solutions
3 Session Plan This no-cost counseling service helps you address stress, relationship and other personal issues you and your family may face. It is staffed by GuidanceConsultantsSM—highly trained master’s and doctoral level clinicians who will listen to your concerns and quickly refer you to in-person counseling (up to 3 sessions per year) and other resources for: › Stress, anxiety and depression › Job pressures › Relationship/marital conflicts › Grief and loss › Problems with children › Substance abuse
Delegate your “to-do” list. Our Work-Life specialists will do the research for you, providing qualified referrals and customized resources for: › Child and elder care › College planning › Moving and relocation › Pet care › Making major purchases › Home repair
Financial Information and Resources Discover your best options. Speak by phone with our Certified Public Accountants and Certified Financial Planners on a wide range of financial issues including: › Getting out of debt › Retirement planning › Credit card or loan problems › Estate planning › Tax questions › Saving for college
Legal Support and Resources Expert info when you need it. Talk to our attorneys by phone. If you require representation, we’ll refer you to a qualified attorney in your area for a free 30minute consultation with a 25% reduction in customary legal fees thereafter. Call about: › Divorce and family law › Real estate transactions › Debt and bankruptcy › Civil and criminal actions › Landlord/tenant issues › Contracts
GuidanceResources® Online Knowledge at your fingertips. GuidanceResources Online is your one stop for expert information on the issues that matter most to you… relationships, work, school, children, wellness, legal, financial, free time and more. › Timely articles, HelpSheetsSM, tutorials, streaming videos and self-assessments › “Ask the Expert” personal responses to your questions › Child care, elder care, attorney and financial planner searches
Free Online Will Preparation Get peace of mind. EstateGuidance® lets you quickly and easily write a will on your computer. Just go to www.guidanceresources.com and click on the EstateGuidance link. Follow the prompts to create and download your will at no cost. Online support and instructions for executing and filing your will are included. You can: › Name an executor to manage your estate › Choose a guardian for your children › Specify your wishes for your property › Provide funeral and burial instructions
Your ComPsych® GuidanceResources® Program CALL ANYTIME Call: 855.387.9727 TDD: 800.697.0353 Online: guidanceresources.com Your company Web ID: ONEAMERICA3 OneAmerica is the marketing name for American United Life Insurance Company® (AUL). AUL markets ComPsych services. ComPsych Corporation is not an affiliate of AUL and is not a OneAmerica company. Copyright © 2016 ComPsych Corporation. All rights reserved. To view the ComPsych HIPAA privacy notice, please go to www.guidanceresources.com/privacy.
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Life and AD&D Providing you peace of mind when traveling
Travel assistance services
TRAVEL ASSISTANCE
•
Emergencies happen, but help is now only a phone call or email away. On Call International® offers a suite of services to help you in your time of need— from small inconveniences like losing your luggage to life-threatening situations — all delivered with a caring, human touch.
• • • • • •
Find comfort in knowing you and your loved ones are protected by the Travel Assistance benefit when traveling more than 100 miles from home for business or leisure. The Travel Assistance benefit protects you when covered under a OneAmerica® company group life insurance policy. It also extends coverage to your spouse, domestic partner and children (under 21 or 25 and living at home as a full- time student) even when they are traveling without you. The Travel Assistance benefit requires no additional premium; however, exclusions do apply.
Medical assistance services •
•
• •
•
•
•
•
•
Pre-trip plan to provide up-to-date information regarding required vaccinations, health risks, travel restrictions and weather conditions. Medical monitoring and review of documentation utilizing professional case managers and medical professionals to ensure appropriate care is received. 24-hour nurse help line to provide clinical assessment, education and general health information. Replacement of prescriptions and eyeglasses that have been lost or stolen by consulting with the prescribing provider to transfer prescription to or arranging an appointment with a local provider. Medical, behavioral or mental health, dental and pharmacy referrals to assist in finding care providers and medical facilities. Coordination of benefits by requesting health information from the participant and attempting to coordinate benefits during an active travel assistance case. Emergency medical evacuation to arrange and coordinate air and/or ground transportation and medical care during transportation to the nearest hospital where appropriate care is available. Medical repatriation to arrange the transport of the participant with a qualified medical attendant, if medically necessary, to their residence or home hospital. Return of remains to arrange the transportation of a participant’s remains to their home in the event of their death while traveling.
•
Pre-trip information 24/7 emergency travel arrangements Translator and interpreter referral Emergency travel funds assistance Legal consultation and referral Lost or stolen travel documents assistance Emergency messaging Lost luggage assistance
24-hour travel assistance Travel Assistance is made available through OneAmerica® by an agreement with On Call International®
1-800-575-5014 (US/Canada) 1-603-898-9172 (call collect from other locations) Email: mail@oncallinternational.com When contacting On Call International, be prepared to provide: • The name of your employer • A phone number where you can be reached
Note: Group life products are issued and underwritten by American United Life Insurance Company® (AUL), Indianapolis, IN., a OneAmerica company. Not available in all states or may vary by state. Travel assistance provided by On Call International®, On Call International is not an affiliate of AUL, and is not a OneAmerica company. On Call International provides noted services for covered individuals and approved dependents. Services may be unavailable in countries currently under U.S. economic or trade santions. Please refer to your policy for covered limits and eligibility details. This is a brief summary of coverage for insured participants. This is not a contract of insurance. Coverage is governed by an insurance policy issued to OneAmerica®. The policy is underwritten by International Insurance Co. of Hannover Ltd. Complete information on the insurance is contained in the Certificate of Insurance on file with OneAmerica. If there is a difference between this program description and the certificate wording, the certificate controls. OneAmerica® is the marketing name for the companies of OneAmerica | OneAmerica.com © 2019 OneAmerica Financial Partners, Inc. All rights reserved.G-33508 12/09/19
97
5STAR
Family Protection Plan
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 98 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Term Life with Terminal Illness and Quality of Life Rider 5Star Life Insurance Company Individual and Group Term Life Insurance with Terminal Illness coverage to age 121 including Quality of Life Benefit Enhanced coverage options for employees. Easy and flexibile enrollment for employers. The 5Star Life Insurance Company’s Family Protection Plan offers both Individual and Group products with Terminal Illness coverage to age 121, making it easy to provide the right benefit for you and your employees. CUSTOMIZABLE With several options to choose from, select the coverage that best meets the needs of your family. TERMINAL ILLNESS ACCELERATION OF BENEFITS Coverage that pays 30% (25% in CT and MI) of the coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months (24 months in IL). PORTABLE Coverage continues with no loss of benefits or increase in cost if you terminate employment after the first premium is paid. We simply bill you directly.
Nearly
85%
of people said they thought most people need life insurance.
Yet only
59%
said that they have coverage themselves.
And
33%
wish their spouse or partner had more life insurance.*
FAMILY PROTECTION Coverage is available for spouses and financially dependent children, even if the employee doesn’t elect coverage on themselves. • Financially dependent children 14 days to 23 years old. CONVENIENCE Easy payment through payroll deduction. PROTECTION YOU CAN COUNT ON Within one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions. QUALITY OF LIFE Benefit that accelerates a portion of the death benefit on a monthly basis, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or • Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision. Underwritten by 5Star Life Insurance Company (a Lincoln, Nebraska company); Administered by NTT Data at 777 Research Drive, Lincoln, NE 68521 FPPi product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD. Quality of Life rider not available in CA. FPPg product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD, VI FPPi/gQOLFlyerR1119 FPPduoQOL_MKT_FLYER_1119
99
FPPi Rate Sheet MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT
Age on Eff. Date 18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 100
$10,000 $9.90 $9.91 $9.98 $10.08 $10.23 $10.43 $10.64 $10.87 $11.11 $11.40 $11.72 $12.08 $12.46 $12.88 $13.33 $13.83 $14.38 $14.98 $15.60 $16.26 $16.93 $17.67 $18.43 $19.19 $20.02 $20.93 $21.94 $23.11 $24.42 $25.88 $27.44 $29.19 $30.99 $32.84 $34.74 $36.71 $38.77 $40.93 $43.22 $45.72 $48.50
$20,000 $13.28 $13.34 $13.46 $13.66 $13.95 $14.35 $14.76 $15.23 $15.72 $16.30 $16.93 $17.65 $18.44 $19.25 $20.17 $21.15 $22.25 $23.46 $24.70 $26.02 $27.37 $28.83 $30.35 $31.88 $33.55 $35.36 $37.39 $39.74 $42.33 $45.27 $48.37 $51.87 $55.49 $59.19 $62.97 $66.94 $71.05 $75.37 $79.95 $84.93 $90.50
$30,000 $16.68 $16.75 $16.96 $17.26 $17.68 $18.28 $18.90 $19.61 $20.33 $21.20 $22.16 $23.23 $24.40 $25.63 $27.00 $28.48 $30.13 $31.96 $33.81 $35.78 $37.80 $40.00 $42.28 $44.58 $47.08 $49.81 $52.83 $56.35 $60.26 $64.65 $69.31 $74.56 $79.98 $85.53 $91.21 $97.15 $103.33 $109.80 $116.68 $124.16 $132.51
Employee Coverage Amounts $40,000 $50,000 $75,000 $20.07 $23.46 $31.94 $20.16 $23.59 $32.13 $20.44 $23.92 $32.62 $20.84 $24.42 $33.37 $21.40 $25.13 $34.44 $22.20 $26.12 $35.94 $23.04 $27.16 $37.50 $23.97 $28.34 $39.25 $24.93 $29.55 $41.06 $26.10 $31.00 $43.26 $27.37 $32.59 $45.63 $28.80 $34.37 $48.31 $30.36 $36.34 $51.25 $32.00 $38.38 $54.32 $33.83 $40.67 $57.76 $35.80 $43.13 $61.44 $38.00 $45.87 $65.57 $40.44 $48.92 $70.12 $42.90 $52.00 $74.75 $45.53 $55.30 $79.69 $48.23 $58.67 $84.75 $51.17 $62.33 $90.26 $54.20 $66.13 $95.94 $57.27 $69.96 $101.69 $60.60 $74.13 $107.94 $64.24 $78.67 $114.75 $68.26 $83.71 $122.32 $72.96 $89.59 $131.13 $78.17 $96.09 $140.87 $84.03 $103.42 $151.88 $90.23 $111.17 $163.50 $97.23 $119.92 $176.63 $104.46 $128.96 $190.19 $111.86 $138.21 $204.06 $119.43 $147.67 $218.25 $127.36 $157.59 $233.13 $135.60 $167.88 $248.57 $144.23 $178.67 $264.75 $153.40 $190.13 $281.94 $163.37 $202.59 $300.62 $174.50 $216.50 $321.50
$100,000 $40.42 $40.66 $41.34 $42.34 $43.75 $45.75 $47.84 $50.17 $52.58 $55.50 $58.67 $62.25 $66.16 $70.25 $74.83 $79.75 $85.25 $91.34 $97.50 $104.08 $110.83 $118.17 $125.75 $133.42 $141.75 $150.84 $160.91 $172.66 $185.67 $200.33 $215.83 $233.33 $251.41 $269.91 $288.83 $308.66 $329.25 $350.83 $373.75 $398.67 $426.50
$125,000 $48.89 $49.21 $50.04 $51.29 $53.07 $55.56 $58.16 $61.09 $64.11 $67.75 $71.71 $76.18 $81.09 $86.19 $91.92 $98.06 $104.94 $112.54 $120.25 $128.48 $136.92 $146.09 $155.56 $165.15 $175.57 $186.92 $199.52 $214.21 $230.46 $248.80 $268.17 $290.04 $312.64 $335.77 $359.42 $384.21 $409.94 $436.92 $465.56 $496.71 $531.50
$150,000 $57.38 $57.75 $58.76 $60.26 $62.38 $65.38 $68.50 $72.01 $75.63 $80.00 $84.76 $90.13 $96.00 $102.13 $109.00 $116.38 $124.63 $133.76 $143.01 $152.88 $163.00 $174.00 $185.38 $196.88 $209.38 $223.01 $238.13 $255.75 $275.26 $297.25 $320.51 $346.76 $373.88 $401.63 $430.01 $459.75 $490.63 $523.00 $557.38 $594.76 $636.51
FPPi Rate Sheet MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT
Age on Eff. Date 66* 67* 68* 69* 70*
$10,000 $49.13 $52.62 $56.58 $61.09 $66.18
$20,000 $91.75 $98.73 $106.67 $115.68 $125.85
$30,000 $134.38 $144.85 $156.75 $170.28 $185.53
Employee Coverage Amounts $40,000 $50,000 $75,000 $177.00 $219.63 $326.19 $190.97 $237.08 $352.38 $206.83 $256.92 $382.13 $224.87 $279.46 $415.94 $245.20 $304.88 $454.06
$100,000 $432.75 $467.67 $507.33 $552.42 $603.25
$125,000 $539.31 $582.96 $632.54 $688.90 $752.44
$150,000 $645.88 $698.25 $757.75 $825.38 $901.63
*Quality of Life not available ages 66 - 70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 14 days through 23 years). $7.15 monthly for $10,000 coverage per child.
FPPiDBQOLMonthlyRates
9/18
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VOYA YOUR BENEFITS PACKAGE
Accident
About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-soserious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.
2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or
usually live paycheck
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 102 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Accident Compass Accident Insurance Enrollment at a glance Affordable insurance that can help you pay for the out-of-pocket costs you may experience after an accident. For the employees of: LifeSchool of Dallas Have you ever dislocated a joint or gotten a deep cut? How about something more severe, like a concussion or broken bone? Most of us have experienced an accident that needed medical attention as least once in our lives. Accident Insurance can help relieve some of the financial stress that goes along with an accidental injury.
as you are and one premium amount covers all of your eligible children. If both you and your spouse are covered under this policy as an employee; then only one, but not both, may cover the same children for Accident Insurance. If the parent who is covering the children stops being insured as an employee, then the other parent may apply for children’s coverage. *The use of “spouse” in this document means a person insured as a spouse as described in the applicable rider. This may include domestic partners or civil union partners as defined by the employer’s plan. Please contact your employer for more information. **The definition of “child” may vary by state. Please contact your employer for more information.
What accident benefits are available?
What is Accident Insurance?
The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs, on or after injury within a set amount of time. Note that there may be some variations by state. For a list of your coverage effective date. The benefit amount depends on standard exclusions and limitations, go to the end of this the type of injury and care received. You have the option to document. For a complete description of your available benefits, elect Accident Insurance to meet your needs. Accident exclusions and limitations, see your certificate of insurance and Insurance is a limited benefit policy. It is not health insurance any benefits. and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. EVENT BENEFIT Accident Hospital Care Other features of Accident Insurance include: Surgery Open abdominal, thoracic • Guaranteed issue: No medical questions or tests are $1,200 Surgery exploratory or without repair $175 required for coverage. Blood, plasma, platelets $600 • Flexible: You can use the benefit payments for any purpose Hospital admission you like. $1,250 • Payroll deductions: Premiums are paid through convenient Hospital confinement Per day up to 365 $375 payroll deductions. Critical care unit confinement per day, up to 15 days $600 • Portable: If you leave your current employer, you can take Rehabilitation facility confinement per day for 90 days $200 your coverage with you. Coma Duration of 14 or more days
How can Accident Insurance help? Below are a few examples of how your Accident Insurance benefits could be used: • Medical expenses, such as deductibles and copays • Home healthcare costs • Lost income due to lost time at work • Everyday expenses like utilities and groceries
Who is eligible for Accident Insurance? • •
•
You—all active employees working 20+ hours per week. Your spouse*—If you have coverage on yourself, you may enroll your spouse, as long as your spouse is not covered under your employer’s plan as an employee. Your spouse will be covered for the same Accident benefits as you are. Your children**—If you have coverage on yourself; your natural children, stepchildren, adopted children or children for whom you are a legal guardian; are eligible to be covered under your employer’s plan, up to the age of 26. Your children will be covered for the same Accident benefits
Transportation per trip, up to 3 per accident Lodging Per day, up to 30 days Family care per child, up to 45 days Accident Care Initial doctor visit Urgent care facility treatment Emergency room treatment Ground ambulance Air ambulance Follow-up doctor treatment Chiropractic treatment up to 6 per accident Medical equipment Physical or occupational therapy up to six per accident Speech therapy up to 6 per accident Prosthetic device (one) Prosthetic device (two or more) Major diagnostic exam Outpatient surgery (one per accident) X-ray
$17,000 $750 $180 $25 $90 $225 $225 $360 $1,500 $90 $45 $120 $45 $45 $750 $1,200 $240 $225 $45
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Accident Common Injuries Burns second degree, at least 36% of the body Burns 3rd degree, at least 9 but less than 35 square inches of the body Burns 3rd degree, 35 or more square inches of the body Skin Grafts Emergency dental work
$1,250
$7,500 $15,000 25% of the burn benefit $350 crown, $90 extraction $100 $350
Eye Injury removal of foreign object Eye Injury surgery Torn Knee Cartilage surgery with no repair or if $225 cartilage is shaved Torn Knee Cartilage surgical repair $800 Laceration1 treated no sutures $30 Laceration1 sutures up to 2” $60 Laceration1 sutures 2” – 6” $240 Laceration1 sutures over 6” $480 Ruptured Disk surgical repair $800 Tendon/Ligament/Rotator Cuff $425 One, surgical repair Tendon/Ligament/Rotator Cuff $825 Two or more, surgical repair Tendon/Ligament/Rotator Cuff $1,225 Exploratory Arthroscopic Surgery with no repair Concussion $225 Paralysis quadriplegia $16,000 Paralysis paraplegia $24,000 Closed/open reduction2 Dislocations Hip joint $3,850/$7,700 Knee $2,400/$4,800 Ankle or foot bone (s) Other than toes $1,500/$3,000 Shoulder $1,600/$3,200 Elbow $1,100/$2,200 Wrist $1,100/$2,200 Finger/toe $275/$550 Hand bone(s) Other than fingers $1,100/$2,200 Lower jaw $1,100/$2,200 Collarbone $1,100/$2,200 25% of the closed Partial dislocations reduction amount Closed/open reduction3 Fractures Hip $3,000/$6,000 Leg $2,500/$5,000 Ankle $1,800/$3,600 Kneecap $1,800/$3,600 Foot Excluding toes, heel $1,800/$3,600 Upper arm $2,100/$4,200 Forearm, Hand, Wrist Except fingers $1,800/$3,600 Finger, Toe $240/$480 Vertebral body $3,360/$6,720 Vertebral processes $1,440/$2,880 Pelvis Except coccyx $3,200/$6,400 Coccyx $400/$800 Bones of face Except nose $1,200/$2,400 Nose $600/$1,200 104
Upper jaw Lower jaw Collarbone Rib or ribs Skull – simple Except bones of face Skull – depressed Except bones of face Sternum Shoulder blade Chip Fractures
$1,500/$3,000 $1,440/$2,880 $1,440/$2,880 $400/$800 $1,400/$2,800 $3,000/$6,000 $360/$720 $1,800/$3,600 25% of the closed reduction amount
1. Laceration benefits are a total of all lacerations per accident. 2. Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a completely separated joint. 3. Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical.
What does my Accident Insurance include? The benefits listed below are included with your Accident Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits. • Sports Accident Benefit: If your accident occurs while participating in an organized sporting activity as defined in the certificate; the accident hospital care, accident care or common injuries benefit will be increased by 25%; to a maximum additional benefit of $1000. If your spouse and/or children are covered for Accident Insurance, their coverage includes this benefit. This benefit only applies to the events in the table above. It does not apply to any of the additional benefits/coverage outlined in this section. • Accidental Death and Dismemberment (AD&D) coverage: If you are severely injured or die as a result of a covered accident, an AD&D benefit may be payable to you or your beneficiary. If your spouse and/or children are covered for Accident Insurance, their coverage includes AD&D. Accidental Death Benefits Benefit Common carrier: If the death occurs as a result of a covered accident on a common carrier, a higher benefit will be payable. Common carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined points or cities. Employee $100,000 Spouse $50,000 Children $25,000 Other Accident Employee $50,000 Spouse $20,000 Children $10,000 Accidental Dismemberment Benefits Loss of both hand or both feet or sight in both $28,000 eyes Loss of one hand or one foot AND the sight of one $22,000 eye Loss of one hand AND one foot $22,000 Loss of one hand OR one foot $12,500 Loss of Two or more fingers or toes $1,800 Loss of one finger or one toe $1,250
Accident • An accident while the covered person is operating a motorized
What optional benefits are available? You may choose to include the optional benefits below with your Accident Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders. • Spouse Accident Insurance: If you have coverage on yourself, you may enroll your spouse, as long as your spouse is not covered under your employer’s plan as an employee. • Your spouse will be covered for the same Accident benefits as you are. • Guaranteed issue: No medical questions or tests are required for coverage. • Children’s** Accident Insurance: If you have coverage on yourself, your natural children, stepchildren, adopted children or children for whom you are a legal guardian will also be covered under your employer’s plan, up to the age of 26. • Your children will be covered for the same Accident benefits as you are. • Guaranteed issue: No medical questions or tests are required for coverage. • One premium amount covers all of your eligible children. • If both you and your spouse are covered under your employer’s plan as an employee, then only one, but not both, may cover the same children for Accident Insurance. If the parent who is covering the children stops being insured as an employee, then the other parent may apply for children’s coverage.
Are there additional non-insurance services available?
• • •
• • •
• •
•
vehicle while intoxicated. Intoxication means the covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred. Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane. War or any act of war, whether declared or undeclared, other than acts of terrorism. Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion. Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor. Riding in or driving any motor-driven vehicle in a race, stunt show or speed test. Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare -paying passenger is not excluded. Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities. Practicing for, or participating in, any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received. Any sickness or declining process caused by a sickness.
Questions? For more information, please contact: •Voya Employee Benefits Customer Service at (877) 236-7564
Voya Travel Assistance: When traveling more than 100 miles from home, Voya Travel Assistance offers enhanced security for your leisure and business trips. You and your dependents can take advantage of four types of services: pre-trip information, emergency personal services, medical assistance services and emergency transportation services.
How much does Accident Insurance cost? All employees pay the same rate, no matter their age. See the chart below for the premium amounts.
Monthly Rates Employee
Employee and Spouse
Employee and Children
Family
$15.18
$24.70
$29.30
$38.82
Rates shown are guaranteed until September 1, 2021 The cost provided below includes Accident Insurance premium and a fee for Voya Travel Assistance.
Exclusions and Limitations* Exclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance and AD&D are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*: • Participation or attempt to participate in a felony or illegal activity.
This offer is contingent upon participation requirements being met. This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Accident Insurance is underwritten by ReliaStar Life Insurance Company (Minneapolis, MN), a member of the Voya® family of companies. Policy Form #RL-ACC3-POL-16; Certificate Form #RL-ACC3-CERT-16; and Rider Forms: Spouse Accident Rider Form #RL-ACC3-SPR-16, Children's Accident Rider Form #RL-ACC3-CHR-16, Accidental Death & Dismemberment (AD&D) Rider Form #RL-ACC3-ADR-16. Form numbers, provisions and availability may vary by state. CN1030-38176-1018 LifeSchool of Dallas, Group #70618-3, Acct #001 Date Prepared: 6/6/2018 17512811/01/2017 ReliaStar Life Insurance Company, a member of the Voya® family of companies
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THE HARTFORD
Critical Illness
YOUR BENEFITS PACKAGE
About this Benefit Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.
$16,500 Is the aggregate cost of a hospital stay for a heart attack.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 106 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Critical Illness GROUP VOLUNTARY CRITICAL ILLNESS INSURANCE BENEFIT HIGHLIGHTS LIFE SCHOOL OF DALLAS
Facing a serious illness can be devastating both emotionally and financially. Major medical insurance may pick up most of the tab, but can still leave out-of-pocket expenses that add up quickly. Critical Illness insurance can provide a lump-sum benefit upon diagnosis that can be used however you choose - from expenses related to treatment, to deductibles or day-to-day costs of living such as the mortgage or your utility bills. To learn more about Critical Illness insurance, visit thehartford.com/ employeebenefits
65% of American cancer survivors did not have sufficient income to cover out-of-pocket expenses for cancer treatment and other incurred debts related to the illness.1
COVERAGE INFORMATION Benefit amounts for covered illnesses are based on the coverage amount in effect for you or an insured dependent at the time of diagnosis.
BENEFITS & FEATURES COVERAGE AMOUNTS Employee Coverage Amount Spouse Coverage Amount
Child(ren) Coverage Amount COVERED ILLNESSES CANCER CONDITIONS Benign Brain Tumor*; Invasive Cancer* Non-invasive Cancer VASCULAR CONDITIONS Heart Attack*; Heart Transplant*; Stroke* Aneurysm; Angioplasty/Stent; Coronary Artery Bypass Graft OTHER SPECIFIED CONDITIONS Coma*; End Stage Renal Failure; Loss of Hearing; Loss of Speech; Loss of Vision; Major Organ Transplant*; Paralysis Bone Marrow Transplant CHILD CONDITIONS Cerebral Palsy; Congenital Heart Disease; Cystic Fibrosis; Muscular Dystrophy; Spina Bifida ADDITIONAL BENEFITS Recurrence – Pays a benefit for a subsequent diagnosis of conditions marked with an asterisk (*) Health Screening Benefit FEATURES Coverage Maximum – Primary Insured & Spouse Coverage Maximum – Child(ren) Ability Assist® EAP2– 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM3 – Administrative and clinical support following serious illness or injury
$5,000; $10,000; $20,000 or $30,000 Greater of $5,000 or 50% of your coverage amount $5,000 BENEFIT AMOUNTS 100% of coverage amount 25% of coverage amount 100% of coverage amount 25% of coverage amount 100% of coverage amount 25% of coverage amount 100% of coverage amount BENEFIT AMOUNTS 100% of original benefit amount $50 Annually DETAILS 500% of coverage amount 300% of coverage amount
107
Critical Illness PREMIUMS
WHEN DOES THIS INSURANCE END?
See the Premium Worksheet.4
This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, or when you reach the age of 80, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered.
WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full -time employee who works at least 20 hours per week on a regularly scheduled basis and are less than age 80. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 19 (or under age 26.
AM I GUARANTEED COVERAGE?
CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP?
This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.
Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.
HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided on the Premium Worksheet. You have a choice of coverage amounts. You may elect insurance for you only, or for you and your dependent (s), by choosing the applicable coverage tier. Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.
WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, within 60 days of the date you have a change in family status, or within 60 days of the completion of any eligibility waiting period established by your employer.
WHEN DOES THIS INSURANCE BEGIN? Subject to any eligibility waiting period established by your employer, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/ care facility).
108
1 Insights From Survivors: Managing the Personal, Emotional and Financial Impact of Cancer, Washington National Institute for Wellness Solutions, 2014. 4 Rates and/or benefits may be changed. Rates are based on the age of the insured person and increase on the policy anniversary date on or following your birthday as you enter each new age category. 5 The Critical Illness policy is guaranteed issue, but does contain a Pre-Existing Condition Limitation. Please refer to the certificate for more information on exclusions and limitations, such as Pre-Existing Conditions. 2 AbilityAssist® services are offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Ability Assist is a registered trademark of The Hartford. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 3 HealthChampion℠ services are provided through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford doesn’t provide basic hospital, basic medical, or major medical insurance. HealthChampion specialists are only available during business hours. Inquiries outside of this timeframe can either request a call-back the next day or schedule an appointment. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Health Champion is a service mark of ComPsych. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. Prepare. Protect. Prevail. With The Hartford. ® 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. 5962f NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details including the provisions, terms, conditions, limitations and exclusions are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Critical Illness Form Series includes GBD-2600, GBD-2700, or state equivalent.
Premium Worksheet Rates and/or benefits can change. Rates are based on the employee’s age and increase as you enter each new age category.
You are considered a tobacco user if you have smoked cigarettes, cigars or a pipe, or used chewing tobacco, nicotine chewing gum or snuff during the 12 months before submitting an application for insurance. VOLUNTARY CRITICAL ILLNESS INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year) NON-TOBACCO USER Benefit Amount
$5,000
$10,000
$20,000
$30,000
Coverage Tier
Under 25 25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Employee Only
$2.08
$2.41
$2.60
$3.11
$4.09
$5.85
$7.73
$10.23
$14.23
$19.61
$26.77
$35.38
Employee & Spouse
$4.14
$4.76
$5.14
$6.14
$8.12
$11.76
$15.69
$20.98
$29.38
$40.38
$55.14
$72.65
Employee & Child(ren)
$5.49
$5.55
$5.27
$5.52
$6.26
$7.96
$9.77
$12.26
$16.24
$21.61
$28.77
$37.38
Employee & Family
$8.11
$8.42
$8.25
$8.94
$10.64
$14.22
$18.08
$23.35
$31.72
$42.71
$57.48
$74.99
Employee Only
$3.27
$3.85
$4.21
$5.22
$7.11
$10.57
$14.32
$19.32
$27.32
$38.07
$52.38
$69.61
Employee & Spouse
$5.32
$6.20
$6.75
$8.24
$11.14
$16.48
$22.28
$30.07
$42.47
$58.84
$80.76 $106.88
Employee & Child(ren)
$6.67
$6.99
$6.88
$7.62
$9.28
$12.69
$16.36
$21.35
$29.32
$40.07
$54.39
Employee & Family
$9.30
$9.86
$9.86
$11.04
$13.66
$18.94
$24.67
$32.44
$44.80
$61.17
$83.10 $109.22
Employee Only
$5.64
$6.75
$7.43
$9.42
$13.16
$20.02
$27.50
$37.49
$53.49
$74.99 $103.62 $138.07
Employee & Spouse
$8.90
$10.53
$11.55
$14.51
$20.16
$30.71
$42.30
$57.85
$82.65 $115.38 $159.23 $211.48
Employee & Child(ren)
$9.05
$9.89
$10.10
$11.83
$15.32
$22.13
$29.54
$39.52
$55.49
Employee & Family
$12.87
$14.19
$14.67
$17.31
$22.69
$33.17
$44.68
$60.22
$84.98 $117.72 $161.57 $213.81
Employee Only
$8.02
$9.65
$10.65
$13.63
$19.20
$29.46
$40.68
$55.66
$79.66 $111.91 $154.85 $206.53
Employee & Spouse
$12.47
$14.86
$16.35
$20.78
$29.19
$44.94
$62.32
$85.63 $122.83 $171.93 $237.70 $316.07
Employee & Child(ren) $11.43
$12.79
$13.32
$16.04
$21.37
$31.58
$42.72
$57.69
$18.52
$19.47
$23.58
$31.71
$47.40
$64.70
$88.00 $125.17 $174.26 $240.04 $318.41
Employee & Family
$16.44
$71.61
$76.99 $105.62 $140.08
$81.66 $113.92 $156.86 $208.54
TOBACCO USER Benefit Amount
$5,000
$10,000
$20,000
$30,000
Coverage Tier
Under 25 25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
$54.60
$65.32
Employee Only
$2.20
$2.64
$3.00
$3.85
$5.57
$8.99
$13.06
$18.61
$27.61
$40.54
Employee & Spouse
$4.38
$5.24
$5.99
$7.71
$11.27
$18.47
$26.98
$38.60
$57.40
$84.04 $113.58 $135.81
Employee & Child(ren)
$5.60
$5.78
$5.67
$6.26
$7.73
$11.10
$15.11
$20.64
$29.62
$42.55
Employee & Family
$8.35
$8.90
$9.10
$10.52
$13.80
$20.93
$29.36
$40.97
$59.74
$86.38 $115.92 $138.14
Employee Only
$3.50
$4.32
$5.01
$6.70
$10.06
$16.84
$24.99
$36.07
$54.08
$79.94 $108.05 $129.50
Employee & Spouse
$5.68
$6.92
$8.00
$10.56
$15.77
$26.33
$38.90
$56.06
$83.87 $123.44 $167.03 $199.98
Employee & Child(ren)
$6.91
$7.46
$7.69
$9.11
$12.23
$18.95
$27.03
$38.10
$56.08
Employee & Family
$9.66
$10.58
$11.11
$13.36
$18.29
$28.79
$41.29
$58.43
$86.20 $125.78 $169.37 $202.32
Employee Only
$6.11
$7.68
$9.04
$12.40
$19.06
$32.56
$48.84
$70.99 $107.01 $158.73 $214.95 $257.84
Employee & Spouse/
$9.62
$11.97
$14.05
$19.15
$29.42
$50.40
$75.54 $109.83 $165.45 $244.59 $331.78 $397.67
Employee & Child(ren)
$9.52
$10.82
$11.71
$14.80
$21.22
$34.67
$50.88
Employee & Family
$13.59
$15.63
$17.17
$21.95
$31.95
$52.86
$77.92 $112.20 $167.78 $246.93 $334.11 $400.01
Employee Only
$8.72
$11.04
$13.06
$18.09
$28.05
$48.27
$72.68 $105.91 $159.95 $237.52 $321.86 $386.19
Employee & Spouse
$13.55
$17.02
$20.11
$27.73
$43.08
$74.48 $112.17 $163.60 $247.03 $365.74 $496.52 $595.36
Employee & Child(ren) $12.13
$14.18
$15.74
$20.50
$30.21
$50.39
$20.68
$23.22
$30.54
$45.60
$76.94 $114.55 $165.97 $249.36 $368.07 $498.86 $597.70
Employee & Family
$17.52
$56.60
$67.33
$81.94 $110.06 $131.50
$73.02 $109.02 $160.73 $216.96 $259.85
$74.73 $107.94 $161.95 $239.52 $323.86 $388.20
109
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 110 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life SchoolFrisco of Dallas ISD Benefits BenefitsWebsite: Website:www.mybenefitshub.com/friscoisd www.mybenefitshub.com/lifeschoolofdallas
Medical Transport EMERGENT PLUS MEMBERSHIP BENEFITS Emergent Air Transportation
In the event of a serious medical emergency, Members have access to emergency air transportation into a medical facility or between medical facilities. Please see your Member Services Agreement for the complete terms, conditions and limitations of this benefit.
Emergent Ground Transportation
In the event of a serious medical emergency, Members have access to emergency ground transportation into a medical facility or between medical facilities. Please see your Member Services Agreement for the complete terms, conditions and limitations of this benefit.
Non-Emergent Inter-Facility Transportation
In the event that a member is in stable condition in a medical facility but requires a heightened level of care that is not available at their current medical facility, Members have access to non-emergent air or ground transportation between medical facilities. Please see your Member Services Agreement for the complete terms, conditions, and limitations of this benefit.
Repatriation/ Recuperation
In the event that a Member is hospitalized more than 100-miles from their home, Members have access to air or ground medical transportation into a medical facility closer to Member’s home for the purposes of recuperation. Please see your Member Services Agreement for the complete terms, conditions and limitations of this benefit.
Did You Know? 16-Million people are sent to the emergency room through a ground or air ambulance every year.* Insurance companies typically DO NOT cover all air and ground ambulance expenses which can result in a bill in excess of $60,000.
Emergent Ground Ambulance transports can cost as much as
Non-Emergent Air Medical transports can cost more than
Emergent Air Ambulance transports often cost more than
$5,000
$20,000
$60,000
MASA MTS PROVIDES ULTIMATE PEACE OF MIND FOR ONLY $14 PER MONTH TO COVER YOU AND YOUR FAMILY! Trust MASA MTS to provide you and your family peace of mind against the financial burden of medical transport bills by enrolling in a MASA MTS membership at an affordable GROUP RATE.
*SOURCE: National Hospital Ambulatory Medical Care Survey The descriptions of the services offered by MASA are for marketing purposes only and do not represent the terms and conditions contained within each applicable Member Services Agreement. Please review the applicable Member Services Agreement for the completed terms and conditions of any service offered by MASA.
111
AURA IDENTITY GUARD
Identity Theft
YOUR BENEFITS PACKAGE
About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.
An identity is stolen every 2 seconds, and takes over
300 hours
to resolve, causing an average loss of $9,650.
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 112 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Identity Theft AURA™ IDENTITY GUARD® ULTIMATE PLAN
Identity and privacy protection to keep you and your family safe from online harm Safeguarding you, your family, and your finances with identity protection, financial tracking, and online security.
Have you wondered: •
• • • • •
Sex offender monitoring Dark web monitoring Human-sourced intelligence Lost Wallet protection Risk management score
POWERFUL FINANCIAL TOOLS • 1-Bureau credit monitoring • Monthly credit score • Credit score tracker • Security freeze assistance • Near real-time alerts • Student loan activity alerts
What can I do to protect my data from getting into the wrong hands? • How do I know if my information has been comprised? Can I protect my children from identity theft? • Can I protect myself and my family on social media? What do BEST-IN-CLASS CUSTOMER CARE I do if my personal information has been stolen? • U.S.-based customer care • End-to-end remediation • Online identity dashboard Aura Identity Guard protects you and your • Mobile App
family against cybercrime.
COMPREHENSIVE IDENTITY PROTECTION • $1M in insurance protection1 of financial losses and legal fees • 24/7 expert guidance, if a threat is detected • Protect your loved ones for one low price with our family plan FASTEST SPEED AND LARGEST BREADTH OF ALERTS1 • Around-the-clock scan of billions of online resources • Reduce exposure to cybertheft • Be alerted within seconds of possible cyberthreats POWERFUL FINANCIAL TOOLS • Keep an eye on your spending and get alerted to suspicious transactions • Access to your credit report and real-time alerts to changes that impact your credit • Complete protection and monitoring of online accounts and passwords
Features that are included in all Aura Identity Guard Plans: PROACTIVE DEVICE & PRIVACY PROTECTION • Safe browsing: Anti-ransomware & anti-malware COMPREHENSIVE IDENTITY PROTECTION • $1 Million insurance with stolen funds reimbursement1 • 401(k) & HSA reimbursement • Compromised credentials • Auto-on monitoring • High-risk transaction monitoring • Bank account transaction monitoring • Address monitoring • Criminal record monitoring • Fictitious identity monitoring • Home title monitoring
Additional features in Aura Identity Guard’s Ultimate Plan: PROACTIVE DEVICE & PRIVACY PROTECTION • Device/cookie tracking protection • E-mail solicitation/junk mail prevention • Data broker list monitoring/removal • Social insight report COMPREHENSIVE IDENTITY PROTECTION • Credit card monitoring • Debit card monitoring POWERFUL FINANCIAL TOOLS • Up to 3-Bureau Credit monitoring • Up to 3-Bureau annual credit
Rates Effective 09/01/2021: Monthly Rates Employee Only Family
$10.60 $19.50
Semi-Monthly Rates Employee Only $ 5.30 Family $ 9.75
Customer Service Concierge customercare@identityguard.com 855-443-7748 1Identity Theft Insurance underwritten by insurance company subsidiaries or affiliates of American International Group‚ Inc. The description herein is a summary and intended for informational purposes only and does not include all terms‚ conditions and exclusions of the policies described. Please refer to the actual policies for terms‚ conditions‚ and exclusions of coverage. Coverage may not be available in all jurisdictions. 0221_EE_PREMIER
113
NBS
Retirement Planning
YOUR YOUR BENEFITS BENEFITS PACKAGE PACKAGE
About this Benefit A 403(b) plan is a U.S. tax-advantaged retirement savings plan available for public education organizations. Only 22% of workers are very confident they will have enough money in retirement.
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 114 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas
Retirement Planning - 403(b) Universal Availability Notice LIFE SCHOOLS OF DALLAS 403(B) PLAN HIGHLIGHTS Visit NBSbenefits.com/403b for additional information Congratulations! You are eligible to participate in the 403(b) retirement plan provided by the Life Schools of Dallas 403(b. ) Contributing to a 403(b) plan will give you peace of mind through financial security during your retirement. A 403(b) plan allows you to contribute a portion of your compensation as a pre-tax or post-tax (Roth) contribution (if allowed by your Employer) in order to save for retirement. Participation in the 403(b) plan is completely voluntary. If you are already contributing to the 403(b) plan, now is a perfect time to increase your contributions. WHAT IS A 403(B) PLAN? A 403(b) plan, also known as a Tax-Sheltered Annuity (TSA), is a taxdeferred retirement plan provided for employees of certain tax exempt, governmental organizations or public education institutions. WHAT ARE THE BENEFITS OF CONTRIBUTING TO A 403(B) PLAN? LOWER TAXES The 403(b) contributions you make can be on a pre -tax basis. This means that the money used to invest in the 403(b) plan is not taxed until the funds are withdrawn. For example, if your federal marginal income tax rate is 25%, and you contribute $100 a month to a 403(b) plan, you have reduced your federal income taxes by nearly $25. In effect, your $100 contribution costs you only $75. The tax savings grow with the size of your 403(b) contribution. TAX-DEFERRED GROWTH In your 403(b) plan, interest and earnings grow tax -deferred. This means that your interest will grow tax-free until the time of your withdrawal. The compounding interest on your 403(b) plan allows your account to grow more quickly than money saved in a taxable account where interest and earnings are taxed each year. TAKING THE INITIATIVE Contributing to a 403(b) retirement plan helps you take control of your future retirement needs. Other sources of retirement income, including state pension plans and Social Security, often do not adequately replace a person ’s salary upon retirement. A 403(b) plan can be a great way to supplement your income at retirement. POSSIBLE TAX CREDITS Pre-tax contributions may put you in a lower tax bracket reducing your overall tax rate. DISTRIBUTIONS FROM THE PLAN Either you or your beneficiary will be able to withdraw your vested balance when one of the following occurs: • Retirement • Termination of Employment • Attainment of Age 59 ½ • Total Disability • Death The vendors may require additional paperwork.
HIGHER LIMITS Annual contribution limits are much higher than those of an IRA.
HOW MUCH CAN YOU CONTRIBUTE TO A 403(B) PLAN? You may elect to save: • 100% of your income up to $19,500 (2021) • Extra $6,500 if age 50+ HOW TO ENROLL IN THE PLAN Your employer has provided investment option(s) for you. A list of approved vendor(s) and the Salary Reduction Agreement (“SRA”) can be found by visiting the National Benefit Services website at http:// www.nbsbenefits.com/non-erisa-403b-forms/ or by contacting NBS (contact information below). Once you have chosen an approved vendor, please open a 403(b) account directly with them. To begin investing, send the completed SRA form to NBS who will work with your employer to begin contributions. INVESTMENT CHOICES Annuity contracts made available through insurance companies or custodial accounts through a retirement account custodian are allowed in 403(b) plans. You will need to contact the vendor for a comprehensive listing and information regarding the available investment options. EXCHANGES As a participant in the 403(b) plan, you have the option to move funds, or “exchange” tax-free between different vendors within the same plan.
ROLLOVERS You also have the option of rolling retirement funds from previous employers to your current employer’s plan, thus simplifying retirement management. ROTH You may also choose to invest part of your income on an after-tax (Roth) basis. Roth contributions are taxed at the time of the investment though contributions and earnings grow tax-free until withdrawn. Qualified distributions will allow you to withdraw your money tax-free. HARDSHIP DISTRIBUTIONS An in-service hardship distribution may be allowed if you satisfy certain criteria. Contact NBS for more information about the requirements. NBS Retirement Service Center 8523 South Redwood Road West Jordan, UT 84088 800.274.0503 ext. 2,5 Fax - 1.800. 597.8206 Contact NBS if you have questions about the retirement plan Life Schools of Dallas Plan Contact Person: Mayda Falcon 132 East Ovilla Road, Suite A Red Oak, TX 75154 1.469.850.5433
LOANS You may borrow up to 50% of your vested balance up to $50,000 (whichever is less). Contact your current vendor about their specific loan provisions. REQUIRED MINIMUM DISTRIBUTIONS (RMD) Distributions are required at age 72. Exceptions may apply 115
WWW.MYBENEFITSHUB.COM/LIFESCHOOLOFDALLAS 116