2022 - 2023 Plan Year
Central Texas Employee Benefits Cooperative
BENEFIT GUIDE EFFECTIVE: 09/01/2022 - 8/31/2023 WWW.CTXEBC.COM
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Table of Contents How to Enroll Annual Benefit Enrollment 1. Section 125 Cafeteria Plan Guidelines 2. Annual Enrollment 3. Eligibility Requirements 4. Helpful Definitions 5. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) Medical - Region 12 Medical - Region 13 Health Savings Account (HSA) Hospital Indemnity Telehealth Dental Vision Disability Life and AD&D Individual Life Cancer Accident Critical Illness Identity Theft
10-17 18-24 25-36 37-42 43 44-45 46 47-49 50-53 54-55 56-60 61-65 66-69 70-71
Emergency Medical Transportation
72-73
Flexible Spending Account (FSA)
74-78
Legal Services
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FLIP TO...
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PG. 4
HOW TO ENROLL
PG. 5
SUMMARY PAGES
PG. 10
YOUR BENEFITS
Benefit Contact Information CTXEBC BENEFITS
TRS ACTIVECARE MEDICAL
TRS HMO MEDICAL
Financial Benefit Services (800) 583-6908 www.ctxebc.com
BCBSTX (866) 355-5999 www.bcbstx.com/trsactivecare
Scott & White HMO (844) 633-5325 www.trs.swhp.org
HEALTH SAVINGS ACCOUNT (HSA)
HOSPITIAL INDEMNITY
TELEHEALTH
EECU (817) 882-0800 www.eecu.org
Aetna (800) 872-3862 www.aetna.com
MDLIVE (888) 365-1663 www.mdlive.com/fbs
DENTAL
VISION
DISABILITY
FCL Dental (877) 493-6282 www.fcldental.com
Superior Vision (800) 507-3800 www.superiorvision.com
Unum (866) 679-3054 www.unum.com
LIFE AND AD&D
INDIVIDUAL LIFE
CANCER
Unum (866) 679-3054 www.unum.com
5Star Life Insurance (866) 863-9753 www.5starlifeinsurance.com
American Public Life (800) 256-8606 www.ampublic.com
ACCIDENT
CRITICAL ILLNESS
IDENTITY THEFT
Voya (800) 955-7736 www.voya.com
Voya (800) 955-7736 www.voya.com
ID Watchdog (800) 774-3772 www.idwatchdog.com
EMERGENCY MEDICAL TRANSPORTATION
FLEXIBLE SPENDING ACCOUNT (FSA)
LEGAL SERVICES
MASA (800) 423-3226 www.masamts.com
National Benefit Services (800) 274-0503 www.nbsbenefits.com
LegalShield (800) 654-7757 www.legalshield.com
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How to Log In
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www.ctxebc.com
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CLICK LOGIN
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ENTER USERNAME & PASSWORD
SUMMARY PAGES
Your Username Is: 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. Password Reset Date: 01/01/2022 If you HAVE NOT logged in since the Password Reset Date above, your Password is: Last Name (Excluding punctuation) followed by the last four (4) digits of your Social Security Number. If you HAVE logged in since the Password Reset Date above, you will use the password that you previously created, NOT the password format listed above.
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Annual Benefit Enrollment
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 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
QUALIFYING EVENTS 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 only if the other individual actually provides the coverage.
Eligibility for Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Government Programs
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Annual Benefit Enrollment
SUMMARY PAGES
Annual Enrollment During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs. •
Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.
• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.
•
Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 30 days of benefit eligible employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.
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Where can I find forms? For benefit summaries and claim forms, go to your benefit website: www.ctxebc.com. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section. How can I find a Network Provider? For benefit summaries and claim forms, go to the CTXEBC benefit website: www.ctxebc.com. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.
If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
Annual Benefit Enrollment
SUMMARY PAGES
Employee Eligibility Requirements
Dependent Eligibility Requirements
Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.
Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, 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.
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 your 2022 benefits become effective on September 1, 2022, you must be actively-at-work on September 1, 2022 to be eligible for your new benefits.
PLAN
MAXIMUM AGE
Medical
To age 26
Hospital Indemnity
To age 26
Dental
To age 26
Vision
To age 26
Life
To age 26
Cancer
To age 26
Critical Illness
To age 26
AD&D
To age 26
Individual Life
To age 26
Accident
To age 26
Identity Theft
To age 26
Emergency Transportation
To age 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. 7
SUMMARY PAGES
Helpful Definitions Actively-at-Work
In-Network
You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual 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 9/1/2022 please notify your benefits administrator.
Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.
Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.
Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.
Calendar Year January 1st through December 31st
Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or preexisting condition exclusion provisions do apply, as applicable by carrier. 8
Out-of-Pocket Maximum The most an eligible or insured person can pay in coinsurance for covered expenses.
Plan Year September 1st through August 31st
Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescription drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
SUMMARY PAGES
HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care taxfree.
Employer Eligibility
A qualified high deductible health plan.
All employers
Contribution Source
Employee and/or employer
Employee and/or employer
Account Owner
Individual
Employer
Underlying Insurance Requirement
High deductible health plan
None
Minimum Deductible
$1,400 single (2022) $2,800 family (2022)
N/A
Maximum Contribution
$3,650 single (2022) $7,300 family (2022)
$2,850 (2022)
Permissible Use Of Funds
Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age Not permitted 65).
Description
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. 25
FLIP TO FOR FSA INFORMATION
PG. 74
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Medical Insurance
EMPLOYEE BENEFITS
TRS ABOUT MEDICAL 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.
For full plan details, please visit your benefit website: www.ctxebc.com
The below rates apply to the following districts: Abbott ISD Aquilla ISD Blum ISD Bynum ISD Covington ISD Dew ISD Gholson ISD
Hallsburg ISD Hamilton ISD Hico ISD Holland ISD Jonesboro ISD Lometa ISD Malone ISD
Mart ISD Meridian ISD Moody ISD Mount Calm ISD Mullin ISD Oglesby ISD Penelope ISD
REGION 12 MEDICAL TRS ActiveCare HD Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$375.00 $1,055.00 $673.00 $1,261.00 TRS ActiveCare 2
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$1,013.00 $2,402.00 $1,507.00 $2,841.00 TRS ActiveCare Primary
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$365.00 $1,029.00 $656.00 $1,232.00 TRS ActiveCare Primary+
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$458.00 $1,120.00 $737.00 $1,409.00 Scott and White HMO
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Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$491.55 $1,232.58 $789.39 $1,418.42
Priddy ISD Riesel ISD Rosebud-Lott ISD Valley Mills ISD Westphalia ISD Whitney ISD Wortham ISD
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Notes
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Medical Insurance
EMPLOYEE BENEFITS
TRS ABOUT MEDICAL 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.
For full plan details, please visit your benefit website: www.ctxebc.com
The below rates apply to the following districts: Orenda Education Center
Central Texas Employee Benefits Cooperative
REGION 13 MEDICAL TRS ActiveCare HD Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$376.00 $1,058.00 $675.00 $1,265.00 TRS ActiveCare 2
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$1,013.00 $2,402.00 $1,507.00 $2,841.00 TRS ActiveCare Primary
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$364.00 $1,026.00 $654.00 $1,228.00 TRS ActiveCare Primary+
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$457.00 $1,117.00 $735.00 $1,405.00 Scott and White HMO
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$491.55 $1,232.58 $789.39 $1,418.4 BCBSTX West Texas HMO
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Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$689.60 $1,672.26 $1,083.58 $1,775.58
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EECU Health Savings Account
EECU Makes It Easy For You To Make The Most Of Your HSA Enclosed is everything you need to learn how to use your HSA.
Getting Started Maximize savings for your healthcare and your future with an EECU HSA, getting started is easy.
Step 1: Sign up for Online Account Access
Step 2: Read This Guide
Step 3: Activate Your Debit Card
At eecu.org home page, hover over “Log In” in the top menu and click “Enroll now”. Then, you can manage your account anytime, anywhere.
Learn how to make contributions, payments and manage your account.
Activate your new HSA Mastercard® Debit Card immediately by following the instructions on the sticker affixed to the front of the card.
Now you’re ready to maximize your savings! Have a question? We’re here for you! Connect with us your way. Online/Mobile: Sign-in for 24/7 account access to check your balance, pay bills and more. Call/Text: (817) 882-0800. Our dedicated member service representatives are available to assist you with any questions. Our hours of operation are Monday through Friday from 8:00 a.m. to 7:00 p.m. CT, Saturday 9:00 a.m. – 1:00 p.m. CT and closed on Sunday. Lost/Stolen Debit Card: Call our 24/7 debit card hotline at (800) 333-9934 Stop by: a local EECU financial center for in-person assistance; find EECU locations & service hours at www.eecu.org/locations.
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EECU Health Savings Account
Here’s How We Make Saving For Healthcare Expenses Easy, Convenient and Valuable
HSA Overview • Requires a qualifying high deductible health plan (HDHP) • Used to pay for qualified medical expenses • Funded by you, your employer or others • Account funds belong to you
Qualified Medical Expenses
Making It Easy
Use your HSA to pay for qualified medical expenses, as defined by the Internal Revenue Service, for yourself, your spouse or tax dependents1. Here are some examples: • Acupuncture
Easy to Contribute
• Ambulance Service
You can make pre-tax, current year contributions through your employer payroll deduction or make post-tax, current year contributions directly online or at an EECU financial center.
• Chiropractor
Easy to Make Payments
• Hearing Aids
EECU offers three easy ways. You can pay qualified medical expenses1 with your EECU HSA Debit Mastercard® through EECU’s free online banking and bill pay or by writing an HSA check (optional, fees apply2). You can also pay out-of-pocket for eligible medical expenses and then reimburse yourself from your HSA.
• Dental Care • Doctor’s Fees • Laboratory Fees • Prescription Drugs • Surgery • Vaccines • Vision Care
Easy to Manage Your Account
• Wheel Chairs
You can easily access your EECU HSA anytime, anywhere online or from your smartphone or tablet at eecu.org and manage your account on the go. Have a question or need help with a transaction, we’re here to help on the phone, online, chat or in person at a financial center.
• X-Rays
Easy to Grow Your EECU HSA is federally insured, pays out a competitive dividend rate based on balance amount and has no monthly fees, so you can maximize your savings.
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A list of Eligible Medical Expenses can be found in IRS Publication 502 - Medical and Dental Expenses.1
Save your receipts – for all qualified medical expenses. EECU does not verify eligibility. You are responsible for making sure payments are for qualified medical expenses.
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EECU Health Savings Account Making It Convenient Here’s How To Contribute Payroll Deductions – your HSA contributions can be deducted from your paycheck on a pre-tax basis. For more information, please contact your employer. Online Contribution – use our online banking Transfer tool to contribute to your account. Simply log in at eecu.org, then hover over “Move Money” in the top menu, then select the type of transfer from an EECU or external checking or savings account to your HSA. (All contributions are classified as current year contributions unless directed otherwise.) Check – use EECU’s mobile deposit feature to deposit a check from your mobile device. You can also stop by an EECU financial center or one of our 5,000 shared financial centers to make a check deposit. Transfer / Rollover – to make a transfer or rollover from an external HSA or MSA, complete and submit the HSA Transfer Form to EECU, and we’ll take care of the rest.
Here’s How To Make Payments 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 fee2. You can use these checks to pay healthcare providers and suppliers.
Here’s How To Manage Your Account Online - check your balance, pay healthcare providers and arrange deposits; sign-up for online banking at www.eecu.org. Mobile - EECU’s mobile app allows you to manage your account on the go; download “EECU Mobile Banking” in Apple’s App Store and Google Play. Contact Member Service – call (817) 882-0800. Our dedicated member service representatives are available to assist you with any questions. Our hours of operation are Monday through Friday from 8:00 a.m. to 7:00 p.m. CT, Saturday 9:00 a.m. – 1:00 p.m. CT and closed on Sunday. If your debit card is lost or stolen, call our 24-hour debit card hotline at (800) 333-9934. Account Statements – monthly account statements show all your account activity for that period. You can receive free online statements or printed statements. You will also receive an IRS 1099 form and a 5498-SA form if you had any contributions or distributions (withdrawals) during the year.
Thank you for choosing EECU for your Health Savings Account. For more information about HSAs, visit www.eecu.org/HSA, call one of our Member Service Representatives at 817-882-0800 or stop by a local EECU financial center. Your Benefits Administrator will also be able to provide you information about your HSA. 1 A list of Eligible Medical Expenses 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/p969.pdf, over-the-counter medications (when prescribed by a doctor) are considered Eligible Medical Expenses for HSA purposes. 2 Call 817-882-0800 or stop by a financial center to order Standard checks at no charge, excludes shipping & handling or order custom checks, prices vary. EECU - December 2021
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EECU Health Savings Account Frequently Asked Questions
Q What is a Health Savings Account (HSA)? A A Health Savings Account allows you to save money, earn interest and spend money on a tax-free basis as long as the money being spent is on qualified medical expenses1. Unused HSA funds roll over from year to year, no “use it or lose it”. You own your HSA and can take it with you when you change medical plans, change jobs or retire. To be eligible to set up an HSA and contribute to an HSA, you must be covered by a qualified High Deductible Health Plan, have no other coverage (e.g. Medicare) and cannot be claimed as a dependent on someone else’s taxes.
Q Who is eligible to open an HSA? A To be an eligible and qualify for an HSA, you must meet the following requirements. • You are covered under a high deductible health plan (HDHP), described later. • You have no other health coverage. • You aren’t enrolled in Medicare. • You can’t be claimed as a dependent on someone else’s tax return.
Q Is there a monthly Maintenance fee? A With EECU’s HSA, there is no monthly maintenance fee. Q If I am age 65 or better and have Medicare can I enroll in an HSA? A At age 65, you become eligible for Medicare and may be automatically enrolled. Enrolling in any Medicare coverage (Parts A, B, C, D, or Medigap) will end HSA eligibility. Keep in mind that if you apply for Social Security benefits at age 65, you will automatically be enrolled in Medicare Part A. However, at age 65, your options expand for using the money that you have saved in the account; this will be described later in these FAQs.
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EECU Health Savings Account Frequently Asked Questions
Q What is a High Deductible Health Plan (HDHP)? A A High Deductible Health Plan is a plan with an annual deductible of at least $1,400 for an Individual or $2,800 for Family coverage in 2022. The maximum out of pocket expenses, which include money applied to your deductible and your coinsurance for covered charges, must be no more than $7,050 for Individuals and no more than $14,100 for Family coverage in 2022. These amounts are set by the Internal Revenue Service and may change based on cost of living/inflation.
Q How does an HSA work? A Health Savings Accounts work with high deductible health insurance plans. This enables consumers to save money on health insurance premiums, since HDHP’s typically cost less than traditional health insurance, while allowing account holders to contribute money to the account to pay out-of-pocket medical expenses up to the deductible. • Contribute: you can make contributions (pre-tax and after-tax) to your HSA. Pre-tax contributions can reduce your taxable income and after-tax contributions are deductible. Contributions can be made by you, your employer or a third party via payroll deduction, online banking transfer or depositing a paper check. Contributions to your HSA as well as any earnings on those contributions grow tax deferred2. • Make Payments: you can pay for qualified medical expenses with your EECU HSA Mastercard® debit card, EECU Online Banking or HSA check (optional3). Payments or withdrawals from your HSA that are used for qualified medical expenses are tax-free. In addition, withdrawals can also be used for your deductible and co-pays. • Manage: you can manage your HSA, check balances and account information, via EECU’s Online Banking and Mobile Banking App. After age 65, all HSA distributions are penalty free, even if not used for qualified medical expenses. However, if you take a distribution that is not used for a qualified medical expense, it will be taxable2.
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EECU Health Savings Account Frequently Asked Questions
Q How much can I contribute annually to an HSA? A Internal Revenue Service contribution limits are: 2022 • Individual coverage: $3,650 • Family coverage: $7,300 And, accountholders age 55 and over can make a HSA catch-up contribution: $1,000.
Q What is a qualified medical expense? A Qualified medical expenses are defined by the Internal Revenue Service and are listed in IRS publication 502. They include expenses that pay for healthcare services, equipment or medications. Examples of IRS-qualified medical expenses1: Acupuncture
Hearing aids (and batteries for use)
Alcoholism treatment
Hospital services
Ambulance
Laboratory fees
Breast reconstruction surgery (mastectomy-related)
Nursing home
Chiropractor
Operations/surgery (excluding unnecessary cosmetic surgery)
Contact lenses Dental treatment (X-rays, fillings, braces, extractions, etc.)
Osteopath
Diagnostic devices (such as blood sugar test kits for diabetics)
Prescription Drugs
Doctor’s office (including physicians, surgeons, specialists or other medical practitioners) visits and procedures
Speech Therapy
Drug addiction treatment Eyeglasses and exams (for medical reasons) Eye surgery (such as laser eye surgery or radical keratotomy)
Physical Therapy Psychiatric care Stop-smoking programs (including nicotine gum or patches) Vasectomy Weight-loss program (to treat a specific disease diagnosed by a physician)
This list is not comprehensive. For a detailed listing, please refer to https://www.irs.gov/pub/irs-pdf/p502.pdf, titled “Medical and Dental Expenses.”
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EECU Health Savings Account Frequently Asked Questions
Q What happens if I need to pay for a qualified medical expense and I don’t have my HSA debit card? A You can use EECU’s online and mobile bill-pay service or you can use another payment method, then reimburse yourself with your HSA funds in one of the following ways: • Transferring funds electronically from EECU’s free online and mobile banking service to another EECU accountor to an account at another financial institution. • Writing yourself a check from your account (if you have an HSA checkbook- optional) • Withdrawing cash from the ATM Be sure to retain all receipts and other documentation related to your payment in the event you are later asked to substantiate an expense for tax purposes.
Q Can I use my funds to pay for my dependents qualified medical expenses? A Once you’ve contributed money to your health savings account, you can use it to pay for qualified medical expenses for yourself, your spouse and your eligible dependents.
Q When I reach age 65, do the rules for withdrawing funds change? A After age 65, the rules for using your HSA funds change in the following way: • Health insurance premiums – you can use your HSA funds tax and penalty-free to pay premiums for employersponsored health coverage or for Medicare, except Medigap. • Nonmedical expenses – although money used for nonmedical expenses will be subject to federal—and usually state—income taxes, after age 65 you will not be subject to the 20 percent penalty fee.
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EECU Health Savings Account Frequently Asked Questions
Q What happens if I contribute too much to my HSA in a year? A Contributions to your HSA that exceed the annual limits set by the IRS can incur tax penalties and/or IRS fees. To avoid penalties and fees, you still have a chance to remove the excess funds by your tax filing deadline, typically April 15. The Internal Revenue Service (IRS) requires EECU to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be reported correctly, you may not withdraw the excess directly. Instead, you must request an excess contribution refund by completing the “HSA Withdrawal Authorization Form” found at www.eecu.org/HSA and mailing it to EECU, Attention: HSA Department, P.O. Box 1777, Fort Worth, TX 76101-9947. We will send you a check for the amount indicated, plus any applicable earnings. You may have to file additional tax forms. Please consult with a tax advisor if you have any questions about your HSA contributions.
Q What happens if I don’t withdraw my excess contributions prior to April 15th of the following year? A You must pay a 6% excise tax on the excess contribution and on any earnings of the excess contribution. If in the next year you decreased your maximum contribution by the amount of your excess contribution made the year before, you do not have to pay the 6% excise tax again. If, however, you leave the excess contribution in, and do not decrease your maximum contribution by the amount of your excess contribution made the year before, you will have to pay the 6% excise tax each year the excess contributions and earnings are in the HSA. Please consult with a tax advisor if you have any questions about your HSA contributions.
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EECU Health Savings Account Frequently Asked Questions
Q What if I use the money to purchase something other than a qualified medical expense? A Money in your HSA is tax-free if it used to pay for qualified medical expenses. Any funds you withdraw from your HSA for nonqualified expenses will be taxed at your income tax rate, plus a 20% penalty. Exceptions to the 20% penalty are for distributions made after the account owner’s death, disability, or attaining age 65.2
Q How do I report withdrawals that are used for nonqualified expenses? A You must report withdrawals for ineligible expenses to the IRS. Check with your tax advisor for details. Q If I withdraw funds from my HSA by mistake, can I return them to my account? A Yes, if you mistakenly withdraw money from your HSA, you can return it to your account. Just complete and return to EECU a “Mistaken Distribution Form”. You must return the funds by April 15 following the year in which you mistakenly withdrew the money. You can access the “Mistaken Distribution Form” online at www.eecu.org/HSA, by contacting EECU Member Services at 817-882-0800 or visiting a local EECU financial center.
Q What are my obligations with an HSA? A As the account owner, you are responsible for funding and maintaining your HSA in accordance with HSA regulations4, including: • Making sure you’re not covered by any plans other than your HDHP • Ensuring that contributions do not exceed your applicable annual IRS maximum • Ensuring that withdrawals for nonqualified expenses are added back to gross income • Keeping records/receipts of your expenses • Completing Form 8889 when you do your annual taxes • Ensuring you do not have any other medical coverage (other than the HDHP) and that you cannot be claimed as a dependent on someone else’s taxes
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EECU Health Savings Account Frequently Asked Questions
Q Is a beneficiary required for my HSA? A You may designate a beneficiary to receive your HSA assets in the event of your death. If you name your spouse as beneficiary, your spouse can treat the HSA as their own. If you designate a non-spouse beneficiary, he or she must take a distibution of the funds. By having a beneficiary in place at the time of your death, the assets of your HSA can be distributed according to the designation. If you do not designate a benificiary, your HSA will be transferred to your estate and included in your final income tax return. It’s a good idea to consult with a tax professional if you have any questions about the tax consequences for a beneficiary designation. To designate a beneficiary, simply complete and return to EECU the Beneficiary Designation form which can be found on our website or you call us and ask for one to be sent to you.
Q How do I update my email address, residential address, phone number or name? A It’s important to make sure that we have your latest contact information, so we can keep you informed about your account. Following are four ways that you may update your contact information. Through EECU Online Banking & Mobile Banking App: see instructions. By Mail: you may write a letter and send it to: EECU, P.O. Box 1777, Fort Worth, TX 76101. By Phone: call (817) 882-0800. In Person: visit any EECU financial center.
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EECU Health Savings Account Frequently Asked Questions
Q What if I already have an HSA? How can I move funds from my current HSA to my EECU HSA? A If you already have an HSA, but not with EECU, you can roll over or transfer your HSA to EECU. If you have any questions regarding this or would like assistance with HSA Rollovers or Transfers, please contact EECU at (817) 882-0800, by secure email or chat online at www.eecu.org or in person at your local EECU financial center. To transfer funds: Instruct your current HSA custodian to transfer your HSA funds to your EECU HSA. There are no restrictions on the number of HSA direct transfers. You do not include the amount transferred in your income for tax purposes, deduct it as a contribution or include it as a distribution from the account.2 1. Open a health savings account with EECU 2. Complete, sign and return to EECU the HSA Transfer Form. EECU will forward it to your current HSA custodian, instructing them to transfer your funds directly to your new EECU HSA. The EECU HSA Direct Transfer Form is available at www.eecu.org/HSA. To roll over funds: Withdraw your HSA funds from your current HSA custodian and then roll over (deposit) them to your EECU HSA, within 60 days after the date you received the funds. You can make only one rollover contribution to an HSA during a one-year period. Rollovers are not subject to the annual contribution limits.2 1. Open a health savings account with EECU 2. Close your existing HSA 3. Deposit the funds with EECU to roll into your new HSA Rollovers and transfers are subject to IRS restrictions. Please contact your tax advisor for additional information.
Q What happens to my EECU HSA if I leave my employer? A All funds in your EECU HSA, including funds contributed by your employer, are yours to keep. If you leave your employer, you can keep your HSA at EECU or transfer your funds to another qualifying HSA.
Q If I’m no longer covered by a high-deductible health plan, can I use funds from the HSA for expenses not covered by my health plan? A Yes, you can withdraw HSA funds tax free for eligible expenses. You don’t need to be enrolled in a high-deductible health plan (HDHP) to withdraw funds from your HSA, but you do need to be enrolled in an HDHP to contribute to the account.
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EECU Health Savings Account Can’t find the answers you need in our FAQs?
Get in touch with us your way. Online/Mobile: Sign-in for 24/7 account access to check your balance, pay bills and more. Call/Text: (817) 882-0800. Our dedicated member service representatives are available to assist you with any questions. Our hours of operation are Monday through Friday from 8:00 a.m. to 7:00 p.m. CT, Saturday 9:00 a.m. – 1:00 p.m. CT and closed on Sunday. Lost/Stolen Debit Card: Call our 24/7 debit card hotline at (800) 333-9934 Stop by: a local EECU financial center for in-person assistance; find EECU locations & service hours at www.eecu.org/locations.
1
Contributions, investment earnings, and distributions are tax free for federal tax purposes if used to pay for qualified medical expenses, and may or may not be subject to state taxation. 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/p969.pdf, over-the-counter medications (when prescribed by a doctor) are considered Eligible Medical Expenses for HSA purposes.
2
For more information consult a tax adviser or your state department of revenue.
3
all (817) 882-0800 or stop by a financial center to order Standard checks at no charge, excludes shipping & handling or order custom checks, C prices vary.
4
See Department of the Treasury, Internal Revenue Service Publication 969, “Health Savings Accounts and Other Tax-Favored Health Plans”
Federally insured by NCUA. National Credit Union Administration, a U.S. Government Agency – Member accounts are federally insured to at least $250,000 and backed by the full faith and credit of the United States Government.
EECU - December 2021
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BENEFIT SUMMARY Central Texas Employee Benefits Cooperative 802477
Aetna Hospital Indemnity
Insurance plans are underwritten by Aetna Life Insurance Company.
Here’s how the plan works:
You have an unexpected event and have to go to the hospital.
You are admitted into the hospital and spend two days there.
You submit your hospital claim to Aetna.
Aetna pays benefits directly to you.
Unless otherwise indicated, all benefits and limitations are per covered person.
The Aetna Hospital Indemnity Plan is a hospital confinement indemnity plan with other fixed indemnity benefits. THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THESE PLANS ARE A SUPPLEMENT TO HEALTH INSURANCE AND ARE NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. These plans provide limited benefits. They pay fixed dollar benefits for covered services without regard to the health care provider's actual charges. These benefit payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider's bills get paid. These benefits are paid in addition to any other health coverage you may have. THIS IS NOT A MEDICARE SUPPLEMENT (MEDIGAP) PLAN. If you are or will become eligible for Medicare, review the free Guide to Health Insurance for People with Medicare available at www.medicare.gov. This policy, alone, does not meet Massachusetts Minimum Creditable Coverage standards.
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Inpatient Stays Covered Benefit Hospital stay - Admission Provides a lump sum benefit for the initial day of your stay in a hospital.
Employer Voluntary Voluntary Paid Buy-Up Buy-Up Plan 1 Plan 2 Plan 4 $500
$1,000
$2,000
$100
$100
$200
$200
$200
$400
$100
$100
$200
$100
$100
$200
Maximum 1 stay per plan year Hospital stay - Daily Pays a daily benefit, beginning on day two of your stay in a non-ICU room of a hospital. Maximum 30 days per plan year Hospital stay - (ICU) Daily Pays a daily benefit, beginning on day two of your stay in an ICU room of a hospital. Maximum 30 days per plan year Newborn routine care Provides a lump-sum benefit after the birth of your newborn. This will not pay for an outpatient birth. Observation unit Provides a lump sum benefit for the initial day of your stay in an observation unit as the result of an illness or accidental injury. Maximum 1 day per plan year Important Note: All daily inpatient stay benefits begin on day two and count toward the plan year maximum.
Portability
Your plan includes a Portability option which allows you to keep your existing coverage by making direct payments to the carrier. You may exercise this option, if your employment ceases for any reason. Refer to your Certificate for additional Portability provisions.
Waiver of premium
If you are in a hospital for more than 30 days in a row, we will waive the premium beginning on the first premium due date that occurs after the 30th day of your stay, through the next 6 months of coverage. During your stay, you must remain employed with the policyholder.
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Exclusions and Limitations
This plan has exclusions and limitations. Refer to the actual policy and certificate to determine which benefits are not payable. The following is a partial list of services and supplies that are generally not covered. However, the plan may contain exceptions to this list based on state mandates or the plan design purchased. Benefits will not be paid for any stay or other service for an illness or accidental injury related to the following: 1. Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping, parachuting, skydiving 2. Any semi-professional or professional competitive athletic contest, including officiating or coaching, for which you receive any payment 3. Act of war, riot, war 4. Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or not 5. Assault, felony, illegal occupation, or other criminal act 6. Care provided by a spouse, parent, child, sibling or any other household member 7. Cosmetic services and plastic surgery, with certain exceptions 8. Custodial Care 9. Hospice services, except as specifically provided in the Benefits under your plan section of the certificate 10. Self-harm, suicide, except when resulting from a diagnosed disorder 11. Violating any cellular device use laws of the state in which the accident occurred, while operating a motor vehicle 12. Care or services received outside the United States or its territories 13. Education, training or retraining services or testing 14. Mental disorders 15. Treatment of substance abuse in a hospital or substance abuse treatment facility 16. Accidental injury sustained while intoxicated or under the influence of any drug intoxicant 17. Exams except as specifically provided in the Benefits under your plan section of the certificate 18. Dental and orthodontic care and treatment 19. Family planning services 20. Any care, prescription drugs, and medicines related to infertility 21. Nutritional supplements, including but not limited to: food items, infant formulas, vitamins 22. Outpatient cognitive rehabilitation, physical therapy, occupational therapy, or speech therapy for any reason 23. Vision-related care
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Questions and Answers Do I have to be actively at work to enroll in coverage? Yes, you must be actively at work in order to enroll and for coverage to take effect. You are actively at work if you are working, or are available to work, and meet the criteria set by your employer to be eligible to enroll.
Can I enroll in the Aetna Hospital Indemnity plan even though I have a Health Savings Account (HSA)? Yes, you can still enroll in the Aetna Hospital Indemnity plan if you have a Health Savings Account.
What is considered a hospital stay? A stay is a period during which you are admitted as an inpatient; and are confined in a hospital or non-hospital residential facility; and are charged for room, board and general nursing services. A stay does not include time in the hospital because of custodial or personal needs that do not require medical skills or training. A stay specifically excludes time in the hospital for observation or in the emergency room unless this leads to a stay.
If I lose my employment, can I take the Hospital Indemnity Plan with me? Yes, you are able to continue coverage under the Portability provision. You will need to pay premiums directly to Aetna.
How do I file a claim? Go to myaetnasupplemental.com and either “Log In” or “Register”, depending on if you’ve set up your account. Click the “Create a new claim” button and answer a few quick questions. You can even save your claim to finish later. You can also print/mail in form(s) to: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 405124079, or you can ask us to mail you a printed form.
What should I do in case of an emergency? In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.
What if I don’t understand something I’ve read here, or have more questions? Please call us. We want you to understand these benefits before you decide to enroll. You may reach one of our Customer Service representatives Monday through Friday, 8 a.m. to 6 p.m., by calling 1-800-607-3366. We’re here to answer questions before and after you enroll.
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Important information about your benefits IN ORDER FOR THE HOSPITAL INDEMNITY BENEFITS TO BE PAYABLE, THE INITIAL DAY OF YOUR STAY AND OTHER SERVICES MUST BE ON OR AFTER YOUR EFFECTIVE DATE OF COVERAGE. Complaints and appeals Please tell us if you are not satisfied with a response you received from us or with how we do business. Call Member Services to file a verbal complaint or to ask for the address to mail a written complaint. You can also e-mail Member Services through the secure member website. If you’re not satisfied after talking to a Member Services representative, you can ask us to send your issue to the appropriate department. If you don’t agree with a denied claim, you can file an appeal. To file an appeal, follow the directions in the letter or explanation of benefits statement that explains that your claim was denied. The letter also tells you what we need from you and how soon we will respond. We protect your privacy We consider personal information to be private. Our policies protect your personal information from unlawful use. By “personal information,” we mean information that can identify you as a person, as well as your financial and health information. Personal information does not include what is available to the public. For example, anyone can access information about what the plan covers. It also does not include reports that do not identify you. When necessary for your care or treatment, the operation of our health plans or other related activities, we use personal information within our company, share it with our affiliates and may disclose it to: your doctors, dentists, pharmacies, hospitals and other caregivers, other insurers, vendors, government departments and third-party administrators (TPAs). We obtain information from many different sources —particularly you, your employer or benefits plan sponsor if applicable, other insurers, health maintenance organizations or TPAs, and health care providers. These parties are required to keep your information private as required by law. Some of the ways in which we may use your information include: Paying claims, making decisions about what the plan covers, coordination of payments with other insurers, quality assessment, activities to improve our plans and audits. We consider these activities key for the operation of our plans. When allowed by law, we use and disclose your personal information in the ways explained above without your permission. Our privacy notice includes a complete explanation of the ways we use and disclose your information. It also explains when we need your permission to use or disclose your information. We are required to give you access to your information. If you think there is something wrong or missing in your personal information, you can ask that it be changed. We must complete your request within a reasonable amount of time. If we don’t agree with the change, you can file an appeal. If you’d like a copy of our privacy notice, call 1-800-607-3366 or visit us at www.aetna.com. If you require language assistance, please call Member Services at 1-800-607-3366 and an Aetna representative will connect you with an interpreter. If you’re deaf or hard of hearing, use your TTY and dial 711 for the Telecommunications Relay Service. Once connected, please enter or provide the Aetna telephone number you’re calling. Si usted necesita asistencia lingüística, por favor llame al Servicios al Miembro a 1-800-607-3366, y un representante de Aetna le conectará con un intérprete. Si usted es sordo o tiene problemas de audición, use su TTY y marcar 711 para el Servicio de Retransmisión de Telecomunicaciones (TRS). Una vez conectado, por favor entrar o proporcionar el número de teléfono de Aetna que está llamando.
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ATTENTION MASSACHUSETTS RESIDENTS: As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL (1-877-623-6765) or visit the Connector website (www.mahealthconnector.org). THIS POLICY, ALONE, DOES NOT MEET MINIMUM CREDITABLE COVERAGE STANDARDS. If you have questions about this notice, you may contact the Division of Insurance by calling 1-617-521-7794 or visiting its website at www.mass.gov/doi. Financial Sanctions Exclusions Clause If coverage provided by this policy violates or will violate any US economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments or reimburse for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or entity, or a country under sanction by the United States, unless permitted under a valid written Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx. Plans are underwritten by Aetna Life Insurance Company (Aetna). This material is for information only and is not an offer or invitation to contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. Hospital Indemnity Policy forms issued in Idaho, Oklahoma and Missouri include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01.
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Welcome to MDLIVE! With MDLIVE, you can visit with a doctor or counselor 24/7 from your home, office or on-the-go.
You have a telehealth benefit giving you virtual care, anywhere. At a price you can afford.
Your virtual doctor is here. Join for free today!
• Available anytime, day or night • Consults by mobile app, video or phone • Prescriptions can be sent to your nearest pharmacy if medically necessary
We treat over 50 routine medical conditions including: • Acne
• Insect bites
• Allergies
• Nausea/vomiting
• Cold/flu
• Pink eye
• Constipation
• Rash
• Cough
• Respiratory problems
• Diarrhea
• Sore throats
• Ear problems
• And more
Download the app.
Join for free. Visit a doctor.
consultmdlive.com 888-365-1663
Copyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.MDLIVE.com/terms-of-use/.
Texas- DenteMax
Passive PPO Dental Plan (100/80/50)
Annual Benefit - Per Person . . . . . . . . . . . . . . . . $1,000 Percentage of Covered Benefits Per Policy Year TYPE I TYPE II TYPE III* DURING THE 1ST YEAR 100% 80% 0% 2ND YEAR AND THEREAFTER 100% 80% 50% * 12-month waiting period Calendar Year Deductible, Per Person $50/150 This deductible applies to Type II and III services Dependent Children Covered to Age 26 Payment is based upon allowable charges in the area in which service is rendered. Services provided at a non-contracting provider are paid at the 90th percentile.
TYPE I (PREVENTIVE SERVICES)
TYPE III (MAJOR SERVICES)
Including: No waiting period Routine Exams ( one per 6 months) Prophylaxis (cleanings-one per 6 months) Emergency exams for dental pain (minor procedures) Fluoride treatments for dependent children under age 19 (one per 12 months) Bitewing X-rays (once per 6 months)
Including: 12 month waiting period Major restorative services (crowns and inlays) Prosthetics (bridges, dentures) Replacement of prosthodontics, dentures, crowns and inlays Denture relines General anesthesia (for services dentally necessary) Space Maintainers
TYPE II (BASIC SERVICES)
ORTHODONTIC SERVICES
Including: No waiting period Periapical X-rays Simple restorative services (fillings) Simple extractions Palliative treatment for dental pain, local anesthesia Endodontics/root canal therapy Periodontics Oral Surgery Sealants for children ages 6-15 (one per tooth) Periapical X-rays Full mouth or panorex X-rays (one per 36 months)
12 month waiting period 50% coverage – children under 19 $1,000 lifetime maximum benefit
Renewal Date: September 1, 2019 Employee Employee + Spouse Employee +Child(ren) Employee + Family
Marketed, Administered and Underwritten By: ——————————————————————————————
FIRST CONTINENTAL LIFE & ACCIDENT INSURANCE CO.
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101 Parklane Blvd, Suite 301 Sugar Land, TX 77478 (281) 313-7150 - (877) 493-6282 Fax (281) 313-7155
$24.84 $51.75 $57.36 $88.51
ODP 185 TX (MKTG) VOLFCL (01/05)
Limitations and Exclusions Covered Expenses Will Not Include and No Benefits Will be Payable: 1.
2.
3.
4.
5. 6.
7. 8.
9.
10. 11.
12.
13.
14. 15.
For any treatment which is for cosmetic purposes or to correct congenital malformations, except for medically necessary care and treatment of congenital cleft lip and palate. To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge within five years of the date of the last placement of these items, unless required because of an accidental bodily injury sustained while the Insured is covered. Replacement is not covered if the item can be repaired. For initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of natural teeth during the same period of continuous coverage. But the extraction of a third molar (wisdom tooth) will not qualify the item for payment. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. Coverage does not include the part of the cost that aplies specifically to replacement of teeth extracted prior to the period of coverage. For addition of teeth to an existing prosthetic appliance or fixed bridge unless for replacement of natural teeth extracted during the same period of continuous coverage. For any expense incurred or procedure begun before the Insured’s current period of continuous coverage. For any expense incurred or procedure begun after the Insured’s insurance under this section terminates, except for a prosthetic appliance, fixed bridge, crown, or inlay or onlay restoration for which both (a) the procedure begins before insurance ends and (b) the item’s final placement is within 90 days after insurance ends. To duplicate appliances or replace lost or stolen appliances. For appliances, restorations or procedures to: a. alter vertical dimension; b. restore or maintain occlusion; c. splint or replace tooth structure lost as a result of abrasion or attrition; or d. treat jaw fractures or disturbances of the temporomandibular joint. For education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control. For broken appointments or the completion of claim forms. For orthodontia service or for any services associated with orthodontic therapy when this optional coverage is not elected and the premium is not paid. For sealants which are: a. not applied to a permanent molar; b. applied before age 6 or after attaining age 16; or c. reapplied to a molar within three years from the date of a previous sealant application. For subgingival curettage or root planing (procedure numbers 4220 and 4341) unless the presence of periodontal disease is confirmed by both x-rays and pocket depth summaries of each tooth involved. Because of an Insured’s injury arising out of, or in the course of, work for wage or profit. For an Insured’s sickness, injury or condition for which he or she is eligible for benefits under any Workers Compensation Act or similar laws.
16. For charges for which the Insured is not liable or which would not have been made had no insurance been in force. 17. For services which are not recommended by a dentist, not required for necessary care and treatment, or do not have a reasonably favorable prognosis. 18. Because of war or any act of war, declared or not, or while on full-time active duty in the armed forces of any country. 19. To an Insured if payment is not legal where the Insured is living when expenses are incurred. 20. For any services related to: equilibration, bite registration or bite analysis. 21. For crowns for the purpose of periodontal splinting. 22. For charges for: any implants; overdentures; precision or semi-precision attachments and associated endodontic treatment; other customized attachments; or specialized prosthodontic techniques or characterizations. 23. For charges for myofunctional therapy, orthognathic surgery or athletic mouthguards. 24. For procedures for which benefits are payable under the employer’s medical expense benefits plan for employees and their dependents. 25. Services or supplies provided by a family member or a member of the Insured’s household. Note: This is a general outline of covered benefits and does not include all the benefits, limitations and exclusions of the policy. See your certificate for details. Predetermination of Benefits: As a service to protect the Insured, First Continental Life & Accident Insurance Co. will provide predetermination of benefits for recommended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps Insured's better understand their coverage. The Insured should submit the treatment plan to First Continental Life & Accident Insurance Co. for review and predetermination of benefits before the service begins.
TAKEOVER BENEFITS Takeover means that you are given credit for waiting periods for like coverage's accumulated under your existing plan. No credit is given for deductibles satisfied under your existing plan. 1. In order to provide Takeover Benefits your employer’s current dental plan must have been in effect continuously for at least 12 months prior to the effective date of this plan. 2. All employees insured on the effective date with continuous coverage from the prior group dental contract are eligible for Takeover Benefits. Waiting periods will be reduced by the amount of time insured under the prior plan. 3. A minimum of three (3) enrolled members are needed for an employer to be eligible for Takeover Benefits. 4. Takeover Benefits must be requested and are subject to the approval of First Continental Life & Accident Insurance Co.
Submission of Claims: First Continental Life & Accident Insurance Co. ATTN: Claims Department 101 Parklane Blvd, Suite 301 45 Sugar Land, TX. 77478
Vision plan benefits for Central Texas Employee Benefits Copays
Services/frequency
Monthly premiums
Exam1
$10
Emp. only
$6.65
Exam
12 months
Eyewear2
$25
Emp. + spouse Emp. + children
$11.36 $12.01
Frame
24 months
Lenses
12 months
Emp. + family
$18.01
Contact lenses
12 months
(Based on date of service)
Benefits through Superior Select Southwest network Exam Frames Lenses (standard) per pair Single vision Bifocal Trifocal Progressive Contact lenses4 Medically necessary contact lenses LASIK vision correction5
In-network
Out-of-network
Covered in full $125 retail allowance
Up to $35 retail Up to $70 retail
Covered in full Up to $25 retail Covered in full Up to $40 retail Covered in full Up to $45 retail See description3 Up to $45 retail $150 retail allowance Up to $80 retail Covered in full Up to $150 retail $200 allowance
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Eye exam copay is a single payment due to the provider at the time of service. 2 Eyewear copay applies to eyeglass lenses / frame and contact lenses. Eyewear copay is a single payment that applies to the entire purchase of eyeglasses (frame and 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 and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit 5 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations
Discount features Non-covered eyewear discount: members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy. The national LASIK network of laser vision correction providers, featuring LasikPlus, offers members special program pricing on services. The program pricing should be verified prior to service.
.
superiorvision.com (800) 507-3800
The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions. 46
Superior Vision of Texas P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com 0119-BSv2/TX
Central Texas Employee Benefits Cooperative Voluntary Disability Insurance Plan Highlights Who is eligible?
You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week.
What is my monthly benefit amount?
You can elect to purchase a benefit of 45%, 55% or 65% of your monthly earnings.
How long do I have to wait to receive benefits?
The elimination period is the length of time you must be continuously disabled before you can receive benefits. Elimination Period Options: Option 1: 0 days/7 days first day hospital Option 2: 14 days/14 days first day hospital Option 2: 30 days/30 days first day hospital Option 3: 90 days/90 days Option 3: 180 days/180 days 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, you are under the regular care of a physician and you are unable to perform any of the material and substantial duties of your regular occupation due to the same sickness or injury. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)
How long will my benefits last?
Age at Disability Less than age 62 Age Age Age Age Age Age Age Age
62 63 64 65 66 67 68 69 or older
Year of Birth On or before 1937 1938 1939 1940 1941 1942 1943 – 1954 1955 1956 1957 1958 1959 On or after 1960
Maximum Period of Payment To Social Security Normal Retirement Age* (see table below) 60 months 48 months 42 months 36 months 30 months 24 months 18 months 12 months *Social Security Normal Retirement Age (SSNRA) 65 years 65 years, 2 months 65 years, 4 months 65 years, 6 months 65 years, 8 months 65 years, 10 months 66 years 66 years, 2 months 66 years, 4 months 66 years, 6 months 66 years, 8 months 66 years, 10 months 67 years 47
When is my coverage effective?
Please see your plan administrator for your effective date.
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 subject to a 3/12 pre-existing condition exclusion. Please see your plan administrator for your eligibility date.
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 insurance would otherwise become effective.
What is my maximum monthly benefit amount?
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.
What else is included Worldwide emergency travel assistance is included with this long term disability with this policy? 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. Does this plan include Yes. Our work-life balance employee assistance program (EAP) provides help with work-life professional advice for a wide range of personal and work-related issues. The balance? 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. 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; Pre-existing conditions (see pre-existing condition section); or Any occupational injury or sickness for Short Term Disability coverage.
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.
48
What is considered a pre-existing condition?
You have a pre-existing condition if: • You received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and • The disability begins in the first 12 months after your effective date of coverage. Benefits under this provision are payable for no more than 90 days of benefit from the date of disability. After 90 days, benefits are subject to a 3/12 preexisting condition exclusion. In no event will benefits be paid beyond the applicable benefit duration. This applies to new hires. Late entrants will be subject to a 3/12 pre-ex.
When does my coverage end?
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. How can I apply for coverage?
To apply for coverage, complete your enrollment online by the enrollment deadline. Check with your plan administrator for your eligibility date, and complete your enrollment online within 31 days of that date.
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 LifeWorks, 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. 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-1776 (1-17) FOR EMPLOYEES 49
Central Texas Employee Benefits Cooperative Voluntary Life and AD&D Insurance Plan Highlights
sgr
Who is eligible for this coverage?
All actively employed employees working at least 20 hours each week for your employer in the U.S. and their eligible spouses and children to age 26.
What are the coverage amounts?
Employee: up to 7 times salary in increments of $10,000; not to exceed $500,000. Spouse: up to 100% of employee amount in increments of $5,000; not to exceed $500,000. Child: up to 100% of employee coverage amount in increments of $1,000; not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and six months is $1,000.
What are the AD&D coverage amounts?
Employee: up to $500,000 in increments of $10,000; not to exceed $500,000. Spouse: 50% of the Employee AD&D amount; not to exceed $250,000. Child: 10% of the Employee AD&D amount; not to exceed $50,000 Note: You may purchase AD&D coverage for yourself regardless of whether you purchase term life coverage. In order to purchase life and AD&D coverage for your dependents, you must buy coverage for yourself.
Can I be denied coverage?
If you and your eligible dependents enroll during before the enrollment deadline, you may apply for any amount of coverage up to $250,000 for yourself and any amount of coverage up to $50,000 for your spouse, without answering any medical questions. If you want coverage over the amount you are guaranteed, you will need to provide answers to health questions. In addition, if you and your eligible dependents do not enroll during this enrollment period, you will have to wait for a future annual enrollment period to apply — and then you will need to answer health questions for the entire amount of coverage you apply for. New employees: To apply for coverage, complete your enrollment within 31 days of your eligibility period. If you apply for coverage after 31 days, or if you choose coverage over the amount you are guaranteed, you will need to complete a medical questionnaire which you can get from your plan administrator. You may also be required to take certain medical tests at Unum’s expense.
Why buy now?
As long as you buy $10,000 of life coverage now, you can buy more coverage later - up to $250,000 - without answering any medical questions.
How do I apply?
To apply for coverage, complete your enrollment form by 9/1/2021. If you were hired after 9/1/2021, complete your enrollment form within 31 days of your eligibility date determined by your employer. If you apply for coverage after your effective date or if you choose coverage over the guaranteed issue amount, you will need to complete a medical questionnaire, which you can get from your plan administrator. You may also be required to take certain medical tests at Unum’s expense.
50
When is coverage effective?
Your coverage is effective 9/1/2021 or the date your application is approved by underwriting, if health questions were required. Insurance coverage 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 insurance would otherwise become effective. For your dependent spouse and children, insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Totally disabled means that as a result of an injury, sickness, or disorder, your dependent spouse and children: are confined in a hospital or similar institution; or are confined at home under the care of a physician for a sickness or injury. Exception: Infants are insured from live birth.
How much does the coverage cost?
Term life Age band
Employee rate Spouse rate per $1,000 per $1,000 <25 $0.06 $0.06 25-29 $0.06 $0.06 30-34 $0.07 $0.07 35-39 $0.09 $0.09 40-44 $0.10 $0.10 45-49 $0.16 $0.16 50-54 $0.27 $0.27 55-59 $0.42 $0.42 60-64 $0.68 $0.68 65-69 $1.26 $1.26 70-74 $2.04 $2.04 75+ $3.02 $3.02 Child life monthly rate is $0.18 for $1,000. One life premium covers all children.
AD&D rate chart – you must purchase life coverage to purchase AD&D coverage AD&D cost
Employee Family
Per $1,000 Per $1,000
Monthly Cost $0.04 $0.07
Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date. Spouse rate is based on your insurance age which is your age immediately prior to and including the anniversary/effective date. Do my life insurance benefits decrease with age?
Coverage amounts will reduce according to the following schedule: Age: 70
Insurance amount reduces to: 50% of original amount
Coverage may not be increased after a reduction.
51
Is the coverage If you retire, reduce your hours or leave your employer, you can continue coverage for portable (can I yourself your spouse and your dependent children at the group rate. Portability is not keep it if I leave my available for people who have a medical condition that could shorten their life expectancy employer)? — but they may be able to convert their term life policy to an individual life insurance policy. Are there any life insurance exclusions or limitations?
Life insurance benefits will not be paid for deaths caused by suicide within the first 24 months after the date your coverage becomes effective. If you increase or add coverage, these enhancements will not be paid for deaths caused by suicide within the first 24 months after you make these changes.
Will my premiums be waived if I’m disabled?
If you become disabled (as defined by your plan) and are no longer able to work, your life premium payments will be waived until your disability period ends.
What does my AD&D insurance pay for?
The full benefit amount is paid for loss of: • • • • •
life; both hands or both feet or sight of both eyes; one hand and one foot; one hand or one foot and the sight of one eye; speech and hearing.
Other losses may be covered as well. Please contact your plan administrator. Are there any AD&D Accidental death and dismemberment benefits will not be paid for losses caused by, exclusions or contributed to by, or resulting from: limitations? • disease of the body; diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM); • suicide, self-destruction while sane, intentionally self-inflicted injury while sane or self-inflicted injury while insane; • war, declared or undeclared, or any act of war; • active participation in a riot; • committing or attempting to commit a crime under state or federal law; • the voluntary use of any prescription or non-prescription drug, poison, fume or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol; • intoxication – “being intoxicated” means you or your dependent’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred. When does my coverage end?
You and your dependents’ coverage under the Summary of Benefits 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 unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage.
In addition, coverage for any one dependent will end on the earliest of: • the date your coverage under a plan ends; 52
• • •
the date your dependent ceases to be an eligible dependent; for a spouse, the date of a divorce or annulment; for dependent coverage, the date of your death.
Unum will provide coverage for a payable claim that occurs while you and your dependents are covered under the policy or plan. 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. © 2017 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. Underwritten by Unum Life Insurance Company of America, Portland, Maine EN-1773 (8-17) FOR EMPLOYEES
53
Family Protection Plan 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
PROTECTION TO COUNT ON
With several options to choose from, employees select the coverage that best meets the needs of their families.
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.
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 employment terminates after the first premium is paid. We simply bill the employee directly.
CONVENIENCE Easy payments through payroll deduction.
QUALITY OF LIFE Optional 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.
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.
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 54
FPPi/gQOLFlyerR1119
FPPduoQOL_MKT_FLYER_1119
FPPi Rate Sheet Monthly Rates with Quality of Life Rider Defined Benefit Employee Coverage Issue Age $10,000 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 66* 67* 68* 69* 70*
$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 $49.13 $52.62 $56.58 $61.09 $66.18
$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 $91.75 $98.73 $106.67 $115.68 $125.85
$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 $134.38 $144.85 $156.75 $170.28 $185.53
$40,000 $20.07 $20.16 $20.44 $20.84 $21.40 $22.20 $23.04 $23.97 $24.93 $26.10 $27.37 $28.80 $30.36 $32.00 $33.83 $35.80 $38.00 $40.44 $42.90 $45.53 $48.23 $51.17 $54.20 $57.27 $60.60 $64.24 $68.26 $72.96 $78.17 $84.03 $90.23 $97.23 $104.46 $111.86 $119.43 $127.36 $135.60 $144.23 $153.40 $163.37 $174.50 $177.00 $190.97 $206.83 $224.87 $245.20
$50,000 $23.46 $23.59 $23.92 $24.42 $25.13 $26.12 $27.16 $28.34 $29.55 $31.00 $32.59 $34.37 $36.34 $38.38 $40.67 $43.13 $45.87 $48.92 $52.00 $55.30 $58.67 $62.33 $66.13 $69.96 $74.13 $78.67 $83.71 $89.59 $96.09 $103.42 $111.17 $119.92 $128.96 $138.21 $147.67 $157.59 $167.88 $178.67 $190.13 $202.59 $216.50 $219.63 $237.08 $256.92 $279.46 $304.88
$75,000 $31.94 $32.13 $32.62 $33.37 $34.44 $35.94 $37.50 $39.25 $41.06 $43.26 $45.63 $48.31 $51.25 $54.32 $57.76 $61.44 $65.57 $70.12 $74.75 $79.69 $84.75 $90.26 $95.94 $101.69 $107.94 $114.75 $122.32 $131.13 $140.87 $151.88 $163.50 $176.63 $190.19 $204.06 $218.25 $233.13 $248.57 $264.75 $281.94 $300.62 $321.50 $326.19 $352.38 $382.13 $415.94 $454.06
$100,000 $125,000 $150,000 $40.42 $48.89 $57.38 $40.66 $49.21 $57.75 $41.34 $50.04 $58.76 $42.34 $51.29 $60.26 $43.75 $53.07 $62.38 $45.75 $55.56 $65.38 $47.84 $58.16 $68.50 $50.17 $61.09 $72.01 $52.58 $64.11 $75.63 $55.50 $67.75 $80.00 $58.67 $71.71 $84.76 $62.25 $76.18 $90.13 $66.16 $81.09 $96.00 $70.25 $86.19 $102.13 $74.83 $91.92 $109.00 $79.75 $98.06 $116.38 $85.25 $104.94 $124.63 $91.34 $112.54 $133.76 $97.50 $120.25 $143.01 $104.08 $128.48 $152.88 $110.83 $136.92 $163.00 $118.17 $146.09 $174.00 $125.75 $155.56 $185.38 $133.42 $165.15 $196.88 $141.75 $175.57 $209.38 $150.84 $186.92 $223.01 $160.91 $199.52 $238.13 $172.66 $214.21 $255.75 $185.67 $230.46 $275.26 $200.33 $248.80 $297.25 $215.83 $268.17 $320.51 $233.33 $290.04 $346.76 $251.41 $312.64 $373.88 $269.91 $335.77 $401.63 $288.83 $359.42 $430.01 $308.66 $384.21 $459.75 $329.25 $409.94 $490.63 $350.83 $436.92 $523.00 $373.75 $465.56 $557.38 $398.67 $496.71 $594.76 $426.50 $531.50 $636.51 $432.75 $539.31 $645.88 $467.67 $582.96 $698.25 $507.33 $632.54 $757.75 $552.42 $688.90 $825.38 $603.25 $752.44 $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 55
AMERICAN PUBLIC LIFE
Cancer
YOUR BENEFITS
About this Benefit Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.
DID YOU KNOW? Breast Cancer is the most commonly diagnosed cancer in women.
If caught early, prostate cancer is one of the most treatable malignancies.
(03/21)
This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 56 Central Texas EBC Benefits Website: www.mybenefitshub.com/CTXEBC
GC14
Limited Benefit Group Specified Disease Cancer Indemnity Insurance
For Employees of Central Texas EBC
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.
Summary of Benefits
Low
High
Cancer Treatment Policy Benefits
Level 1
Level 4
Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period
$10,000
$20,000
Hormone Therapy - Maximum of 12 treatments per calendar year
$50 per treatment
$50 per treatment
Experimental Treatment
paid in same manner and under the same maximums as any other benefit
Cancer Screening Rider Benefits
Level 1
Level 1
Diagnostic Testing - 1 test per calendar year
$50 per test
$50 per test
Follow-Up Diagnostic Testing - 1 test per calendar year
$100 per test
$100 per test
Medical Imaging - per calendar year
$500 per test/ 1 per calendar year
$500 per test/ 1 per calendar year
Surgical Rider Benefits
Level 1
Level 1
Surgical
$30 unit dollar amount Max $3,000 per operation
$30 unit dollar amount Max $3,000 per operation
Anesthesia
25% of amount paid for covered surgery
Bone Marrow Transplant - Maximum per lifetime
$6,000
$6,000
Stem Cell Transplant - Maximum per lifetime
$600
$600
Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime
$1,000/$100
$1,000/$100
Patient Care Rider Benefits
Level 1
Level 3
Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent Children (1-30 days) Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent Children (31+ days)
$100 $200 $100 $200
$200 $400 $400 $800
Outpatient Facility - Per day surgery is performed
$200
$400
Attending Physician - Per day of Hospital Confinement
$30
$40
Dread Disease - Per day of Hospital Confinement (1-30 days / 31+ days)
$100/$100
$200/$400
Extended Care Facility - Up to the same number of Hospital Confinement Days
$100 per day
$200 per day
Donor
$100 per day
$200 per day
Home Health Care - Up to the same number of Hospital Confinement Days
$100 per day
$200 per day
Hospice Care - Up to maximum of 365 days per lifetime
$100 per day
$200 per day
US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days / 31+ days)
$100/$100
$200/$400
Miscellaneous Care Rider Benefits
Level 1
Level 4
Cancer Treatment Center Evaluation or Consultation - 1 per lifetime
Not Included
$750
Evaluation or Consultation Travel and Lodging - 1 per lifetime
Not Included
$350
Second / Third Surgical Opinion - per diagnosis of cancer
$300/$300
$300/$300
Drugs and Medicine - Inpatient / Outpatient (maximum $150 per month)
$150 per confinement $50 per prescription
$150 per confinement $50 per prescription
Hair Piece (Wig) - 1 per lifetime
$150
$150
actual coach fare or $0.40 per mile $0.40 per mile $50 per day
actual coach fare or $0.75 per mile $0.75 per mile $100 per day
actual coach fare or $0.40 per mile $0.40 per mile $50 per day
actual coach fare or $0.75 per mile $0.75 per mile $100 per day
Blood, Plasma and Platelets
$300 per day
$300 per day
Ambulance - Ground/Air - Maximum of 2 trips per Hospital Confinement for all modes of transportation combined
$200/$2,000 per trip
$200/$2,000 per trip
Inpatient Special Nursing Services - per day of Hospital Confinement
$150 per day
$150 per day
Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Lodging - up to a maximum of 100 days per calendar year Family Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Family Lodging - up to a maximum of 100 days per calendar year
57
APSB-22339(TX)-0320 FBS Central Texas EBC
Page 1 of 4
GC 14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Miscellaneous Care Rider Benefits Con’t.
Level 1
Level 2
Outpatient Special Nursing Services - Up to same number of Hospital Confinement days
$150 per day
$150 per day
Medical Equipment - Maximum of 1 benefit per calendar year
Not Included
$150
Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year
$25 per visit/$1,000
$25 per visit/$1,000
Waiver of Premium
Waive Premium
Waive Premium
Internal Cancer First Occurrence Rider Benefits
Level 1
Level 1
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$2,500
$2,500
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$3,750
$3,750
Heart Attack/Stroke First Occurrence Rider Benefits
Level 1
Level 1
Lump Sum Benefit - Maximum 1 per Covered Person per lifetime
$2,500
$2,500
Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime
$3,750
$3,750
Intensive Care Unit
$600 per day
$600 per day
Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit
$300 per day
$300 per day
Hospital Intensive Care Unit Rider Benefits
Total Monthly Premiums by Plan** Issue Ages 18 +
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
Low
High
Low
High
Low
High
Low
High
$19.60
$29.81
$35.90
$53.45
$27.30
$41.12
$35.90
$53.45
**Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.
Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.
Cancer Treatment Benefits Eligibility
You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application. A covered person is a person who is eligible for coverage under the certificate and for whom the coverage is in force. An eligible dependent means your lawful spouse; your natural, adopted or stepchild who is under the age of 26; and/or any child under the age of 26 who is under your charge, care and control, and who has been placed in your home for adoption, or for whom you are a party in a suit in which adoption of the child is sought; or any child under the age of 26 for whom you must provide medical support under an order issued under Chapter 154 of the Texas Family Code, or enforceable by a court in Texas; or grandchildren under the age of 26 if those grandchildren are your dependents for federal income tax purposes at the time application for coverage of the grandchild is made.
Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.
Only Loss for Cancer
The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be 58
APSB-22339(TX)-0320 FBS Central Texas EBC
submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, incontestability and pre-existing condition exclusion for such increase will be based on the effective date of such increase.
Termination of Certificate
Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.
Termination of Coverage
Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim. Page 2 of 4
GC 14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Cancer Screening Benefits Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.
Surgical Benefits
Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.
Patient Care Benefits Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.
Only Loss for Cancer or Dread Disease
Pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This rider also covers other conditions or diseases directly caused by cancer or the treatment of cancer. This rider does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer except for conditions specifically provided in the dread disease benefit. A hospital is not an institution, or part thereof, used as: a place of rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long-term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.
Miscellaneous Benefits Waiver of Premium
When the certificate is in force and you become disabled, we will waive all premiums due including premiums for any riders attached to the certificate. Disability must be due to cancer and occur while receiving treatment for such cancer. You must remain disabled for 60 continuous days before this benefit will begin. The waiver of premium will begin on the next premium due date following the 60 consecutive days of disability. This benefit will continue for as long as you remain disabled until the earliest of either of the following: the date you are no longer disabled; the date coverage ends according to the termination provisions in the certificate; or the date coverage ends according to the termination provisions in this rider. Proof of disability must be provided for each new period of disability before a new waiver of premium benefit is payable.
Limitations and Exclusions
No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. APSB-22339(TX)-0320 FBS Central Texas EBC
Termination of Cancer Screening, Surgical, Patient Care & Miscellaneous Benefit Riders
The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.
Internal Cancer First Occurrence Benefits
Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
Limitations and Exclusions
We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.
Heart Attack/Stroke First Occurrence Benefits
Pays a lump sum benefit amount when a covered person receives a first diagnosis of heart attack or stroke. Only one benefit per covered person per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.
Limitations and Exclusions
We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war (if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request); participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).
Pre-Existing Condition Exclusion
No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a Pre-Existing Condition. 59
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GC 14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of a covered person’s death or the date the lump sum benefit amount for heart attack or stroke has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent, as defined in the policy.
Hospital Intensive Care Unit Benefits
Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.
Limitations and Exclusions
For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war (if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request); participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).
Optionally Renewable
This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.
Portability Rider
When the portability rider is in effect and coverage is not continued under COBRA, you have the option to port your coverage when the policy terminated for a reason other than non-payment of premium or cancelation or termination of the policy by APL. Evidence of insurability will not be required. You must make an election to port coverage and submit the first premium due within 31 days from the date APL notified the policyholder of your termination of coverage. All future premiums will be billed directly to you. Portability coverage will be effective on the day after coverage ends under the policy and any applicable exclusion periods or incontestability periods not yet met under the current policy, will only apply for the period of time that remains. The benefits, terms and conditions of the ported coverage will be the same as those under the policy immediately prior to the date the portability option was elected, except as stated in this paragraph. Once ported coverage is in effect, the termination of ported coverage section, as shown in the portability rider, prevails all other termination provisions of the policy, certificate and any attached riders. Your coverage levels cannot be increased or decreased. Ported coverage may include any eligible dependent(s) who were covered under the policy at the time of termination. No eligible dependent may be added to the ported coverage except as provided in the newborn and adopted child provision set out in your certificate. An eligible dependent may be removed at any time. Premiums will be adjusted accordingly. Termination of the policy will not terminate ported coverage. The benefits, terms and conditions of the ported coverage will be the same as if the group policy had remained in full force and effect, with no further obligation of the policyholder. Any premium collected beyond the termination date will be refunded promptly. This will not prejudice any claim that originated prior to the date termination took effect.
Termination
This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.
2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Specified Disease Cancer Indemnity Insurance | (03/20) | FBS 60
APSB-22339(TX)-0320 FBS Central Texas EBC
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Compass Accident Insurance Enrollment at a glance
For the employees of: Central Texas Employee Benefits Cooperative #70097-5 What is Accident Insurance? Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs while you are not at work, on or after your coverage effective date. The benefit amount depends on the type of injury and care received. Your employer provides Accident Insurance to meet your needs. Accident 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. Features of Accident Insurance include: • Guaranteed issue: No medical questions or tests are required for coverage. • Flexible: You can use the benefit payments for any purpose you like. • Portable: If you leave your current employer or retire, you can take your coverage with you.
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
What accident benefits are available? The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your injury within a set amount of time. Note that there may be some variations by state. For a list of standard exclusions and limitations, go 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. Event
Benefit
Accident hospital care Surgery open abdominal, thoracic
$1,200
Surgery exploratory or without repair Blood, plasma, platelets Hospital admission Hospital confinement per day, up to 365 days Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day, up to 90 days Coma duration of 14 or more days Transportation per trip, up to three per accident Lodging per day, up to 30 days Family care per child per day, up to 45 days
$175 $600 $1,250 $375 $600 $200 $17,000 $750 $180 $25
Accident care Initial doctor visit Urgent care facility treatment Emergency room treatment Ground ambulance Air ambulance
$90 $225 $225 $360 $1,500
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Follow-up doctor treatment Chiropractic treatment up to six 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
$90 $45 $120 $45 $45 $750 $1,200 $240 $225 $45
Common injuries Burns second degree, at least 36% of the body Burns third degree, at least nine but less than 35 square inches of the body Burns third degree, 35 or more square inches of the body
Skin grafts Emergency dental work Eye injury removal of foreign object Eye injury surgery Torn knee cartilage surgery with no repair or if cartilage is shaved
Torn knee cartilage surgical repair 1 Laceration treated no sutures 1 Laceration sutures up to 2” 1 Laceration sutures 2” – 6”
$7,500 $15,000 25% of the burn benefit $350 crown, $90 extraction $100 $350 $225 $800 $30 $60 $240
1
Laceration sutures over 6” Ruptured disk surgical repair Tendon/ligament/rotator cuff exploratory arthroscopic surgery with no repair
Tendon/ligament/rotator cuff one, surgical repair Tendon/ligament/rotator cuff two or more, surgical repair Concussion Paralysis - paraplegia Paralysis - quadriplegia
$480 $800 $425 $825 $1,225 $225 $16,000 $24,000 2
Dislocations
Closed/open reduction $3,850/$7,700 $2,400/$4,800 $1,500/$3,000 $1,600/$3,200 $1,100/$2,200 $1,100/$2,200 $275/$550
Hip joint Knee Ankle or foot bone(s) other than toes Shoulder Elbow Wrist Finger/toe Hand bone(s) other than fingers Lower jaw Collarbone Partial dislocations
$1,100/$2,200 $1,100/$2,200 $1,100/$2,200 25% of the closed reduction amount
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ReliaStar Life Insurance Company, a member of the Voya family of companies.
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$1,250
3
Fractures
Closed/open reduction $3,000/$6,000 $2,500/$5,000 $1,800/$3,600 $1,800/$3,600 $1,800/$3,600
Hip Leg Ankle Kneecap Foot excluding toes, heel Upper arm Forearm, hand, wrist except fingers Finger, toe Vertebral body Vertebral processes Pelvis except coccyx Coccyx
$2,100/$4,200 $1,800/$3,600 $240/$480 $3,360/$6,720 $1,440/$2,880 $3,200/$6,400 $400/$800
Bones of face except nose Nose Upper jaw Lower jaw Collarbone Rib or ribs
$1,200/$2,400 $600/$1,200 $1,500/$3,000 $1,440/$2,880 $1,440/$2,880 $400/$800
Skull – simple except bones of face Skull – depressed except bones of face Sternum Shoulder blade Chip fractures
$1,400/$2,800 $3,000/$6,000 $360/$720 $1,800/$3,600 25% of the closed reduction
1
Laceration benefits are a total of all lacerations per accident. 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. 2
Who is eligible for Accident Insurance? • • •
You—All active employees working 20+ hours per week. Your spouse*— Coverage is available only if employee coverage is elected. Your children**— to age 26. Coverage is available only if employee coverage is elected.
*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information.
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. o If your spouse and/or children are covered for Accident Insurance, their coverage includes this benefit. o 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. o If your spouse and/or children are covered for Accident Insurance, their coverage includes AD&D. ®
ReliaStar Life Insurance Company, a member of the Voya family of companies.
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AAccidental Death Benefits
Benefit $100,000 $50,000 $25,000
Employee Spouse Children Other accident Employee Spouse Children
$50,000 $20,000 $10,000
Accidental Dismemberment Benefits Loss of both hand or both feet or sight in both eyes Loss of one hand or one foot AND the sight of one eye Loss of one hand AND one foot Loss of one hand OR one foot Loss of two or more fingers or toes Loss of one finger or one toe
$28,000 $22,000 $22,000 $12,500 $1,800 $1,250
How much does Accident Insurance cost? All employees within the same class 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
$12.20
$19.00
$19.90
$26.70
Rates shown are guaranteed until September, 2020.
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ReliaStar Life Insurance Company, a member of the Voya family of companies.
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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. • An accident while the covered person is operating a motorized 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. *See the certificate of insurance and riders for a complete list of available benefits, exclusions and limitations. *Definition and limitation/exclusion may vary by state.
Questions? Where do I get more information? For more information or to access the certificate of insurance, please call the Voya Employee Benefits Customer Service Team at (877) 236-7564
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, 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.
CN0221-31181-0218 Central Texas Employee Benefits Cooperative, Group #70097-5, Date Prepared: 05/08/2017 177546-04/01/2017 ®
ReliaStar Life Insurance Company, a member of the Voya family of companies.
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Compass Critical Illness Insurance Enrollment at a glance
For the employees of: Central Texas Employee Benefits Cooperative #70097-5 What is Critical Illness Insurance? Critical Illness Insurance pays a lump-sum benefit if you are diagnosed with a covered illness or condition on or after your coverage effective date. Critical Illness 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. Features of Critical Illness Insurance include: • Guaranteed Issue: No medical questions or tests are required for coverage. • Flexible: You can use the benefit payments for any purpose you like. • Portable: If you leave your current employer or retire, you can take your coverage with you.
What benefits are available? Critical Illness Insurance provides a benefit payment for the following illnesses and conditions. Covered illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness Benefit amount unless otherwise stated. For a complete description of your benefits, along with applicable provisions, conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any riders.
Base Module • • • •
Heart attack* Stroke Coronary artery bypass Coronary obstruction (25%) Coma
• • •
Major organ failure Permanent paralysis End stage renal (kidney) failure
*Cardiac arrest is not a heart attack.
Module A • •
Benign brain tumor Deafness
• •
Occupational HIV Blindness
Module B • • •
Multiple sclerosis Amyotrophic lateral sclerosis (ALS) Parkinson’s disease
• •
Alzheimer’s disease Infectious disease
Cancer Module • •
Cancer Skin cancer (10%)
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•
Carcinoma in situ (25%)
Who is eligible for Critical Illness Insurance? • • •
You—all active employees working 20+ hours per week. Your spouse*— Coverage is available only if employee coverage is elected. Your children**— to age 26. Coverage is available only if employee coverage is elected.
*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information. **The definition of “child” may vary by state. Please contact your employer for more information.
How many times can I receive the Maximum Critical Illness Benefit? Usually you are only able to receive the Maximum Specified Disease Benefit once for each covered condition. Your plan includes the Recurrence Benefit, which allows you to receive a benefit for the same condition a second time. In order for the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment. If you have reached the benefit limit by receiving the maximum benefit for each covered condition, you may choose to end your coverage; however, if you have coverage for your spouse and/or children, you must continue your coverage in order to keep their coverage active. Please see your certificate of coverage for details.
What additional benefits does my Critical Illness Insurance include? The benefits listed below are included with your Critical Illness coverage. There may be some variation by state. 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. •
Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. You may only receive a benefit payment once per year, even if you complete multiple health screening tests. o Examples of health screening tests include but are not limited to: Pap test, serum cholesterol test for HDL and LDL levels, mammography, colonoscopy, and stress test on bicycle or treadmill. o The annual benefit amount is $50 for completing a health screening test. o If your spouse and/or children are covered for Critical Illness Insurance, they are also covered by the Wellness Benefit. Your spouse’s benefit amount is also $50. The benefit for child coverage is 50% of your benefit amount per child with an annual maximum of $100 for all children.
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ReliaStar Life Insurance Company, a member of the Voya family of companies.
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How much does Critical Illness Insurance cost? See the chart below for the premium amounts. Employee Coverage Monthly Rates Includes Wellness Benefit Rider Uni-Tobacco Attained Age
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
Under 30
$2.65
$5.30
$7.95
$10.60
$13.25
$15.90
30-39
$3.05
$6.10
$9.15
$12.20
$15.25
$18.30
40-49
$5.60
$11.20
$16.80
$22.40
$28.00
$33.60
50-59
$11.60
$23.20
$34.80
$46.40
$58.00
$69.60
60-64
$18.15
$36.30
$54.45
$72.60
$90.75
$108.90
65-69
$23.50
$47.00
$70.50
$94.00
$117.50
$141.00
70+
$32.85
$65.70
$98.55
$131.40
$164.25
$197.10
Spouse Coverage*
Children Coverage
Monthly Rates
Monthly Rates
Includes Wellness Benefit Rider
Includes Wellness Benefit Rider
Uni-Tobacco Coverage Amount
Rate
$9.45
$1,000
$0.31
$7.10
$10.65
$2,500
$0.78
$6.55
$13.10
$19.65
$5,000
$1.55
50-59
$14.75
$29.50
$44.25
$10,000
$3.10
60-64
$23.20
$46.40
$69.60
65-69
$29.15
$58.30
$87.45
70+
$39.50
$79.00
$118.50
Attained Age
$5,000
$10,000
$15,000
Under 30
$3.15
$6.30
30-39
$3.55
40-49
*Spouse rates are based on the age of the employee. Rates shown are guaranteed until September 2020.
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ReliaStar Life Insurance Company, a member of the Voya family of companies.
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Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*: • Participation or attempt to participate in a felony or illegal activity. • Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane. • War or any act of war, whether declared or undeclared, other than acts of terrorism. • Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion. • Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor. th
Benefits reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70 birthday, however, premiums do not reduce as a result of this benefit change. *See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.
Questions? Where do I get more information? For more information please call Voya Employee Benefits Customer Service Team at (877) 236-7564
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. Critical Illness Insurance is underwritten by ReliaStar Life ® Insurance Company, a member of the Voya family of companies. Policy Form #RL-CI3-POL-12; Certificate Form #RL-CI3-CERT12; and Rider Forms: Spouse Critical Illness Rider Form #RL-CI3-SPR-12, Children's Critical Illness Rider Form #RL- CI3-CHR-12, Wellness Benefit Rider Form #RL- CI3-WELL-12 Form numbers, provisions and availability may vary by state.
CN0223-31343-0218 Central Texas Employee Benefits Cooperative, Group #70097-5, Date Prepared: 05/08/2017 177620-03/27/2017
®
ReliaStar Life Insurance Company, a member of the Voya family of companies.
69
Identity Theft Is Growing Better Protect You and Your Family
2X MORE
identity theft
Fraud continues to grow more complex. And, it is becoming harder for consumers and identity theft victims to manage the intricacies on their own. Fraudsters are taking
reported to the FTC in 2020.¹
advantage of consumers' increased digital dependence to steal personal and financial information—doubling the amount of identity theft reports to the FTC in 2020.1
Easy & Affordable Identity Protection ID Watchdog helps warn you when your personal information is stolen and helps you better protect yourself and your family from identity fraud—when stolen information is used for illicit gain. You’ll have greater peace of mind knowing you don’t have to face the complexities of identity theft alone.
Why Choose ID Watchdog? Advanced Identity Theft Detection
Greater Protection & Control
Fully Managed Identity Restoration
We scour billions of data points—
We've got you covered with lock
If you become a victim, you don’t
public records, transaction records,
features for added control over
have to face it alone. One of our
social media and more—to search
your credit report(s) to help keep
certified resolution specialists
for signs of potential identity theft.
identity thieves from opening
will fully manage the case for you
new accounts in your name.
until your identity is restored.
More for Families. Our family plan helps you better protect the identities of your loved ones of all ages. We offer more features that help protect minors than any other provider.
A Leader in Detection & Prevention for four years running and a two-time Leader in Resolution.
ID Watchdog is here for you 24/7/365. Reach our in-house customer care team at 866.513.1518. Enroll in this valuable benefit today.
1
Consumer Sentinel Network Data Book 2020, Federal Trade Commission
70
Powerful Features Included in Both ID Watchdog Plans Control & Manage
Monitor & Detect
Support & Restore
• Financial Accounts Monitoring
• Dark Web Monitoring1
• Social Account Monitoring
• Data Breach Notifications
• Fully Managed Resolution Services including Pre-Existing Conditions
• Registered Sex Offender Reporting
• High-Risk Transactions Monitoring2
• Customizable Alert Options
• Subprime Loan Monitoring2
• Equifax Blocked Inquiry Alerts
• Public Records Monitoring
• National Provider ID Alerts
• USPS Change of Address Monitoring • Identity Profile Report
• Online Resolution Tracker • Lost Wallet Vault & Assistance • Deceased Family Member Fraud Remediation • Credit Freeze Assistance
• Credit Score Tracker
More for Families:
Adult family members receive full-featured, customizable accounts. Help better protect children with Equifax Child Credit Lock & Equifax Child Credit Monitoring PLUS features with this icon
Plan-Specific Features Credit Report Monitoring3 Credit Report(s)4 & VantageScore Credit Score(s) Credit Report Lock5 Identity Theft Insurance6 401K/HSA Stolen Funds Reimbursement6 Subprime Loan Block2 within the monitored lending network
1B
Platinum
1 Bureau
3 Bureau
1 Bureau Monthly
1 Bureau Daily & 3 Bureau Annually
1 Bureau
Multi-Bureau
Up to $1 Million
Up to $1 Million
-
Social Account Takeover Alerts
-
Integrated Fraud Alerts
-
7
With a fraud alert, potential lenders are encouraged to take extra steps to verify your identity before extending credit.
Employee
$8.95/month
$12.95/month
Employee + Family
$15.95/month
$23.95/month
1 Bureau = Equifax® | Multi-Bureau = Equifax, TransUnion® | 3 Bureau = Equifax, Experian®, TransUnion
What You Need to Know
The credit scores provided are based on the VantageScore 3.0 model. For three-bureau VantageScore credit scores, data from Equifax, Experian, and TransUnion are used respectively. Any one-bureau VantageScore uses Equifax data. Third parties use many different types of credit scores and are likely to use a different type of credit score to assess your creditworthiness.
Enroll in this valuable benefit at idwatchdog.com/myplan/clientcampaign (1)Dark Web Monitoring scans thousands of internet sites where consumers’ personal information is suspected of being bought and sold, and is constantly adding new sites to those it searches. However, the internet addresses of these suspected internet trading sites are not published and frequently change, so there is no guarantee that ID Watchdog is able to locate and search every possible internet site where consumers’ personal information is at risk of being traded. (2)The monitored network does not cover all businesses or transactions. (3)Monitoring from TransUnion and Experian will take several days to begin. (4)Under certain circumstances, access to your Equifax Credit Report may not be available as certain consumer credit files maintained by Equifax contain credit histories, multiple trade accounts, and/or an extraordinary number of inquiries of a nature that prevents or delays the delivery of your Equifax Credit Report. If a remedy for the failure is not available, the product subscription will be cancelled and a full refund will be made. (5)Locking your Equifax or TransUnion credit report will prevent access to it by certain third parties. Locking your Equifax or TransUnion credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax or TransUnion credit report include: companies like ID Watchdog and TransUnion Interactive, Inc. which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state, and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make pre-approved offers of credit or insurance to you. To opt out of preapproved offers, visit www.optoutprescreen.com. (6)The Identity Theft Insurance is underwritten and administered by American Bankers Insurance Company of Florida, an Assurant company. Please refer to the actual policies for terms, conditions, and exclusions of coverage. Coverage may not be available in all jurisdictions. Review the Summary of Benefits (www.idwatchdog.com/terms/insurance). (7)The Integrated Fraud Alert feature is made available to consumers by Equifax Information Services LLC and fulfilled on its behalf by Identity Rehab Corporation. © 2021 ID Watchdog. Other product and company names are property of their respective owners. EE-1P07670CG0721
71
DID YOU KNOW?
25PEOPLE
MILLION
are sent to the emergency room through ground or air ambulance every year*.
Insurance companies may not cover all air and ground ambulance expenses which can result in max in-network out-of-pocket** costs of:
$8,700 Individual $17,400 Family Ground ambulance out-of-network transportation costs may be even higher than in-network since the No Surprises Act does not apply to ground ambulance at this time.
EMERGENT PLUS MEMBERSHIP BENEFITS A MASA MTS Membership provides the ultimate peace of mind at an aff ordable rate for emergency ground and air transportation assistance expenses within the continental United States, Alaska, Hawaii, and while traveling in Canada, regardless of whether the provider is in or out of your group healthcare benefi ts network. After the group health plan pays its portion, MASA works with providers to make certain our Members have no out-of-pocket expenses~ for emergency ambulance transportation assistance and other related services.
Emergency Air Ambulance Coverage1
MASA MTS covers out-of-pocket expenses associated with emergency air transportation to a medical facility for serious medical emergencies deemed medically necessary for you or your dependent family member.
Emergency Ground Ambulance Coverage1
MASA MTS covers out-of-pocket expenses associated with emergency ground transportation to a medical facility for serious medical emergencies deemed medically necessary for you or your dependent family member.
Hospital to Hospital Ambulance Coverage1
MASA MTS covers out-of-pocket expenses that you or a dependent family member may incur for hospital transfers, due to a serious emergency, to the nearest and most appropriate medical facility when the current medical facility cannot provide the required level of specialized care by air ambulance to include medically equipped helicopter or fixed-wing aircraft.
Repatriation to Hospital Near Home Coverage1
MASA MTS provides services and covers out-of-pocket expenses for the coordination of a Member’s nonemergency transportation by a medically equipped, air or ground ambulance in the event of hospitalization more than one hundred (100) miles from the Member’s home if the treating physician and MASA MTS’ Medical Director says it’s medically appropriate and possible to transfer the Member to a hospital nearer to home for continued care and recuperation.
Contact Your Representative, to learn more:
72 MASAEPLUS_B2B_CB_FLR_V2_031722
The information provided in this product information sheet is for informational purposes only. The benefits listed and the descriptions thereof do not represent the full terms and conditions applicable for usage and may only be offered in some memberships. Premiums and benefits vary depending on the benefits selected. Commercial air and Worldwide coverage are not available in all territories. For a complete list of benefits, premiums, and full terms, conditions, and restrictions, please refer to the applicable member services agreement for your territory. MASA MTS products and services are not available in AK, NY, WA, ND, and NJ. MASA MTS utilizes third-party transportation service providers for all transportation services. MASA Global, MASA MTS and MASA TRS are registered service marks of MASA Holdings, Inc., a Delaware corporation. Void where prohibited by law. ~If a member has a high deductible health plan that is compatible with a health savings account, benefits will become available under the MASA membership for expenses incurred for medical care (as defined under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfies the applicable statutory minimum deductible under IRC section 223(c) for high-deductible health plan coverage that is compatible with a health savings account. COVERAGE TERRITORIES: 1. All coverage provided by this membership is limited to the continental United States, Alaska, Hawaii, and Canada, and must originate and conclude therein.
SOURCES: *ACEP NOW 2014 ** Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2022 and Pharmacy Benefit Manager Standards. May 5, 2021.
1250 S. Pine Island Rd., Suite 500, Plantation, FL 33324 MASAEPLUS_B2B_CB_FLR_V2_031722
800-643-9023 I www.masamts.com 73
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$24,000
$24,000
Health FSA
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Dependent care FSA
$1,500
$0
Total pre-tax contributions
-$3,000
$0
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$21,000
$24,000
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-$7,200
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Healthcare Expense Account
Sample Expenses
Medical Expenses •
Acupuncture
•
Fertility treatment
•
Physical exams
•
Addiction programs
•
First aid (e.g., bandages, gauze)
•
Pregnancy tests
•
Adoption (medical expenses for baby birth)
•
Hearing aids & batteries
•
Prescription medicines or drugs
•
Alternative healer fees
•
Hypnosis (for treatment of illness)
•
Ambulance
Incontinence products (e.g., Depends, Serene)
Psychiatrist/psychologist (for mental illness)
•
•
•
Physical therapy
•
Body scans
•
Joint support bandages and hosiery
•
Speech therapy
•
Breast pumps
•
Lab fees
•
Vaccinations
•
Care for mentally handicapped
•
Menstrual Products*
•
Vaporizers or humidifiers
•
Chiropractor
•
Copayments
Monitoring device (blood pressure, cholesterol)
•
•
Weight loss program fees (if prescribed by physician)
•
Crutches
•
•
Wheelchair
•
Diabetes (insulin, glucose monitor)
•
Eye patches
Non-prescription medicines or drugs (vitamins/supplements without a prescription are not eligible)*
*After January 1, 2020
Dental Expenses
Vision Expenses
•
Artificial teeth
•
Dentures
•
Braille - books & magazines
•
Eyeglasses
•
Copayments
•
Orthodontia expenses
•
Contact lenses
•
Laser surgery
•
Deductible
•
Preventative care at dentist office
•
Contact lens solutions
•
Office fees
•
Dental work
•
Bridges, crown, etc.
•
Eye exams
•
Guide dog and upkeep/ other animal aid
Items that generally do not qualify for reimbursement •
Personal hygiene (e.g., deodorant, soap, body powder, sanitary products. Does not include menstrual products)
•
Exercise equipment**
•
•
Haircare (e.g., hair color, shampoo, conditioner, brushes, hair loss products)
Nutritional and dietary supplements (e.g., bars, milkshakes, power drinks, Pedialyte)**
•
Skin care (e.g., moisturizing lotion, lip balm)
•
Sleep aids (e.g., snoring strips)**
•
Vitamins**
•
Weight reduction aids (e.g., Slimfast, appetite suppressant)**
•
Addiction products**
•
Cosmetic surgery**
•
Health club or fitness program fees**
•
Cosmetics (e.g., makeup, lipstick, cotton swabs, cotton balls, baby oil)
•
Homeopathic supplement or herbs**
•
Counseling (e.g., marriage/family)
•
Household or domestic help
•
Dental care - routine (e.g., toothpaste, toothbrushes, dental floss, antibacterial mouthwashes, fluoride rinses, teeth whitening/bleaching)**
•
Laser hair removal
•
Massage therapy**
**Portions of these expenses may be eligible for reimbursement if they are recommended by a licensed medical professional as medically necessary for treatment of a specific medical condition.
Salt Lake78 City, UT - Headquarters | Dallas, TX | San Diego, CA | Honolulu, HI (800) 274-0503 | service@nbsbenefits.com | www.nbsbenefits.com TM
R
Save with these incredible MEMBERPERKS Your LegalShield and IDShield memberships are simply amazing. And in addition to the privileges that are already yours, we have added these MEMBERPERKS with hundreds of merchants and thousands of discounts. Members can access savings at both national and local companies on everyday purchases such as tickets, electronics, apparel, travel and more. Members have the opportunity to save, on average, over $2,000 per year. MEMBERPERKS can save you enough to pay for your membership for years to come!
RECEIVE EXCLUSIVE DISCOUNTS
Access your members-only discounts in categories such as: APPAREL
HOME SERVICES
AUTOMOTIVE
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BOOKS, MOVIES & MUSIC OFFICE & BUSINESS CELL PHONES ELECTRONICS FINANCE FLOWERS & GIFTS FOOD
REAL ESTATE & MOVING SERVICES SPORTS & OUTDOORS TICKETS & ENTERTAINMENT
WHAT MEMBERS ARE SAYING: “MEMBERPerks pays for my membership!” — Martha S. “I saved 20% at Advance Auto and I also saved 30% on movie tickets on date night with my wife. This membership is it!” — Andre E. “I am receiving 8% off my Verizon cell phone monthly charge!” — Paulette M.
TRAVEL
HEALTH & WELLNESS
Enjoy preferred member pricing on some of your favorite brands and services.
AND MANY MORE!
Getting Started
To sign up, simply login at legalshield.com, click on the Resources tab, then click on MEMBERPERKS. If you don’t already have an account, follow the simple on-screen instructions to make an account with your personal or work email and LegalShield membership number. These benefits are for LegalShield and IDShield members. All offers or promotions are subject to change without notice.79 SHEET_MEMBERPerks_051818
2022 - 2023 Plan Year
Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the CTXEBC Benefits Website. This summary does not replace or amend the underlying plan documentation. In the event of a discrepancy between this summary and the plan documentation the plan documentation governs. All plans and benefits described in this summary may be discontinued, increased, decreased, or altered at any time with or without notice. Rate Sheet General Disclaimer: The rate information provided in this guide is subject to change at any time by your employer and/or the plan provider. The rate information included herein, does not guarantee coverage or change or otherwise interpret the terms of the specific plan documentation, available at the CTXEBC Benefits Website, which may include additional exclusions and limitations and may require an application for coverage to determine eligibility for the health benefit plan. To the extent the information provided in this summary is inconsistent with the specific plan documentation, the provisions of the specific plan documentation will govern in all cases.
WWW.CTXEBC.COM 80
