2022 - 2023 Plan Year
GRAPEVINE-COLLEYVILLE ISD
BENEFIT GUIDE EFFECTIVE: 09/01/2022 - 8/31/2023 WWW.GCISDBENEFITS.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 Hospital Indemnity Telehealth Health Savings Account (HSA) Dental Vision Accident Disability Cancer Life and AD&D Flexible Spending Account (FSA)
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PG. 4
HOW TO ENROLL
PG. 6
SUMMARY PAGES
PG. 11
YOUR BENEFITS
Benefit Contact Information GCISD BENEFITS
GCISD BENEFITS OFFICE
MEDICAL
Financial Benefit Services (866) 914-5202 www.gcisdbenefits.com
Marlena Moreno (817) 251-5577 marlena.moreno@gcisd.net
Allegiance Group #1008109 (855) 999-6808 https://www.ubc-benefits.com/ gcisd-benefits
HOSPITAL INDEMNITY
TELEHEALTH
HEALTH SAVINGS ACCOUNT
The Hartford Group #395308 (866) 547-4205 www.thehartford.com
MDLIVE (888) 365-1663 www.consultmdlive.com
EECU (800) 333-9934 www.eecu.org
DENTAL
VISION
ACCIDENT
Cigna Group #3335893 (800) 244-6224 www.mycigna.com
Superior Vision Group #30386 (800) 507-3800 www.superiorvision.com
The Hartford Group #395308 (866) 547-4205 www.thehartford.com
DISABILITY
CANCER
LIFE AND AD&D
The Hartford Group #395308 (866) 547-4205 www.thehartford.com
American Public Life Group #14828 (800) 356-8606 www.ampublic.com
Unum Group #657072 (800) 858-6843 www.unum.com
FLEXIBLE SPENDING ACCOUNT (FSA)
EMPLOYEE ASSISTANCE PROGRAM (EAP)
403(b)/457 PLANS
National Benefit Services (800) 274-0503 www.nbsbenefits.com
Deer Oaks (866) 327-2400 www.deeroakseap.com
National Benefits Services (800) 274-0503 www.nbsbenefits.com
Select “MDLIVE as a Benefit” and “FBS” as Organization
user/password: gvinecolley
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All Your Benefits One App Employee benefits made easy through the FBS Benefits App! Text “FBS GCISD” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment: •
Benefit Resources
•
Online Enrollment
•
Interactive Tools
•
And more!
App Group #: FBSGCISD
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Text “FBS GCISD” to (800) 583-6908 OR SCAN
How to Log In 1
www.gcisdbenefits.com
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CLICK LOGIN
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ENTER USERNAME & PASSWORD Your Username Is: Your email in THEbenefitsHUB. (Typically your work email) Your Password Is: Four (4) digits of your birth year followed by the last four (4) digits of your Social Security Number If you have previously logged in, you will use the password that you 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
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 eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
Q&A
Where can I find forms? For benefit summaries and claim forms, go to your benefit website: www.gcisdbenefits.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 Grapevine-Colleyville ISD benefit website: www.gcisdbenefits.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.
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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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
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Dental
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Hospital Indemnity
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Vision
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Cancer
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Flexible Spending Account (FSA)
IRS Tax Dependent
Voluntary Life
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Health Savings Account (HSA)
IRS Dependent covered on your HDHP
Accident
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EAP
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Telehealth
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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.
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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
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 prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
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. 9
SUMMARY PAGES
HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)
Flexible Spending Account (FSA) (IRC Sec. 125)
Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care tax-free.
Employer Eligibility
A qualified high deductible health plan.
All employers
Contribution Source Account Owner Underlying Insurance Requirement
Employee and/or employer Individual
Employee and/or employer Employer
High deductible health plan
None
Description
Minimum Deductible Maximum Contribution
$1,400 single (2022) $2,800 family (2022) $3,650 single (2022) $7,300 family (2022)
N/A $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 65).
Not permitted
Year-to-year rollover of account balance?
Yes, will roll over to use for subsequent year’s health coverage.
No. Access to some funds may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
FLIP TO FOR HSA INFORMATION
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PG. 15
FLIP TO FOR FSA INFORMATION
PG. 25
Medical Insurance
EMPLOYEE BENEFITS
Allegiance 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.gcisdbenefits.com
Benefits for UBC Member The Cigna Open Access Plus Network provides you with access to healthcare professionals nationwide to address your health concerns. The UBC plans offer a range of coverage options to best meet the needs of you and your family. This provides you a great deal of flexibility and the option to save significantly on your health insurance premiums. Choice and Control The Cigna Open Access Plus Network provides access to 17,000 facilities and more than 1,000,000 healthcare professionals. Value-HD
Basic-HD Standard Nationwide Network—No PCP referrals
Enhanced
Lowest Premiums of the plans
Low Premiums
Low Deductibles and Out of Pocket Maximums
Lowest Deductibles and Out of Pocket Maximums
Copays for doctor visits before you meet deductible (Limited to 4 per year)
HSA Compatible Plan
Copays for doctor visits
Copays for doctor visits
Free Generic Drugs
Free Generic Drugs
No Drug Deductible Free Generic Drugs
No Drug Deductible Low Copays for Brand Drugs
Please review plan choices and elect the plan that best fits your family needs. Plan details are available on the benefit website home page under MEDICAL. Current TRS Medical Elections have been rolled as follows: • • •
TRS-AC HD to Basic Plan HD TRS-AC Primary to Standard Plan TRS-AC Primary plus to Enhanced Plan
• •
TRS Scott and White to Enhanced Plan TRS AC2 to Enhanced Plan
ID Card replacements maybe ordered by calling Allegiance or online at: www.AskAllegiance.com/UBC-LevelFunded Plans>FORMS. Carrier Contact information on page 3 of this guide. Prescription questions may be directed to 800.933.0765 or rxbenefits.com 11
Medical Insurance
EMPLOYEE BENEFITS
Allegiance
Medical Monthly Premiums Value Plan HD
Total Mo. Premium
Employer Contribution
Employee Cost
Employee Only
$335.00
$285.00
$50.00
$1,000.00
$285.00
$715.00
$625.00
$285.00
$340.00
$1,200.00
$285.00
$915.00
Total Mo. Premium
Employer Contribution
Employee Cost
$397.00
$285.00
$112.00
$1,221.00
$285.00
$936.00
$761.00
$285.00
$476.00
$1,465.00
$285.00
$1,180.00
Standard Plan
Total Mo. Premium
Employer Contribution
Employee Cost
Employee Only
$425.00
$285.00
$140.00
$1,306.00
$285.00
$1,021.00
$814.00
$285.00
$529.00
$1,568.00
$285.00
$1,283.00
Enhanced Plan
Total Mo. Premium
Employer Contribution
Employee Cost
Employee Only
$525.00
$285.00
$240.00
$1,387.00
$285.00
$1,102.00
$896.00
$285.00
$611.00
$1,737.00
$285.00
$1,452.00
Employee and Spouse Employee and Child(ren) Employee and Family Basic Plan HD Employee Only
Employee and Spouse Employee and Child(ren) Employee and Family
Employee and Spouse Employee and Child(ren) Employee and Family
Employee and Spouse Employee and Child(ren) Employee and Family
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Hospital Indemnity
EMPLOYEE BENEFITS
The Hartford ABOUT HOSPITAL INDEMNITY This is an affordable supplemental plan that pays you should you be inpatient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance.
For full plan details, please visit your benefit website: www.gcisdbenefits.com
The Hartford’s Hospital Indemnity (HI) insurance pays a cash benefit if you or an insured dependent (spouse or child) are confined in a hospital for a covered illness or injury. Even with the best primary health insurance plan, out-of-pocket costs from a hospital stay can add up. The benefits are paid in lump sum amounts to you, and can help offset expenses that primary health insurance doesn’t cover (like deductibles, co-insurance amounts or co- pays), or benefits can be used for any non-medical expenses (like housing costs, groceries, car expenses, etc.).
INFORMATION
Claims Claim form is on the benefit website, group number and carrier contact details on page 3 of this guide. Coverage Information You have a choice of three hospital indemnity plans, which allows you the flexibility to enroll for the coverage that best meets your needs. Benefit amounts are based on the plan in effect for you or an insured dependent at the time the covered event occurs.
OPTION 1
Coverage Type Covered Events HSA Compatible BENEFITS HOSPITAL CARE OPTION 1 $500 First Day Hospital Confinement Up to 1 day per year $100 Daily Hospital Confinement (Day 2+) Up to 90 days per year $200 Daily ICU Confinement (Day 2+) Up to 30 days per year FEATURES OPTION 1 Included Ability Assist® EAP3 – 24/7/365 access to help for financial, legal or emotional issues Included HealthChampionSM4 – Administrative & clinical support following serious illness or injury Hospital Indemnity Plan Premiums Option 1 $9.09 Employee Only $18.80 Employee and Spouse $17.37 Employee and Child(ren) $28.34 Employee and Family
OPTION 2 On and off-job (24 hour) Illness and injury Yes
OPTION 3
OPTION 2 $1,000 $200 $400 OPTION 2 Included
OPTION 3 $2,000 $200 $400 OPTION 3 Included
Included
Included
Option 2 $18.19 $37.61 $34.74 $56.68
Option 3 $29.32 $52.94 $52.42 $79.87
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Telehealth
EMPLOYEE BENEFITS
MDLive ABOUT TELEHEALTH Telehealth provides 24/7/365 access to board-certified doctors via telephone or video consultations that can diagnose, recommend treatment and prescribe medication. Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.
For full plan details, please visit your benefit website: www.gcisdbenefits.com
Grapevine Colleyville ISD provides Telemedicine with MDLIVE for you and your dependents at no cost to you! Employees need to list dependents and elect MDLIVE for self and family during Open Enrollment to receive this great employer provided benefit. MDLIVE provides you access to Board-certified doctors 24/7 from your mobile device or computer. Prescriptions can be sent to your nearest pharmacy if medically necessary. While MDLIVE does not replace your primary care physician, it is a convenient and cost-effective option when you need care and: • Have a non-emergency issue and are considering a convenience care clinic, urgent care clinic or emergency room for treatment? • Are on vacation or away from home? • Are unable to see your primary care physician? MDLIVE treats over 50 routine medical conditions including: • Acne • Allergies • Cold/flu • Constipation • Cough • Diarrhea • Earache • Insect bites • Nausea/vomiting • Pink eye • Rash • Respiratory problems • Sore throats • And more Do not use telemedicine for serious or life-threatening emergencies. 14
Registration is Easy Enroll you and your family in MDLIVE during your Open Enrollment walk through. After your benefit becomes effective, set up your account with MDLIVE by providing medical history and pharmacy choices so you are ready to use this valuable service when and where you need it. • Online – www.consultmdlive.com • Phone – 888-365-1663 • Mobile – download the MDLIVE mobile app to your smartphone or mobile device • Select - “MDLIVE as a benefit” and “FBS” as Employer/ Organization Telehealth Employee and Family
$0.00 (Provided by GCISD)
Health Savings Account (HSA) EECU
EMPLOYEE BENEFITS
ABOUT HSA A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used. Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP). For full plan details, please visit your benefit website: www.gcisdbenefits.com
A Health Savings Account (HSA) is more than a way to help you and your family cover health care costs – it is also a taxexempt tool to supplement your retirement savings and cover health expenses during retirement. An HSA can provide the funds to help pay current health care expenses as well as future health care costs. A type of personal savings account, an HSA is always yours even if you change health plans or jobs. The money in your HSA (including interest and investment earnings) grows tax-free and spends tax-free if used to pay for qualified medical expenses. There is no “use it or lose it” rule — you do not lose your money if you do not spend it in the calendar year — and there are no vesting requirements or forfeiture provisions. The account automatically rolls over year after year.
HSA Eligibility You are eligible to open and contribute to an HSA if you are: • Enrolled in an HSA-eligible High Deductible Health Plan (HDHP) • Not enrolled in Medicare or TRICARE • If you enroll in an HSA and FSA, the FSA becomes a Limited Purpose FSA and may only be used for Dental and Vision, not medical expenses. • Not eligible to be claimed as a dependent on someone else’s tax return You can use the money in your HSA to pay for qualified medical expenses now or in the future. You can also use HSA funds to pay health care expenses for your dependents, even if they are not covered by the HDHP. Maximum Contributions Your HSA contributions may not exceed the annual maximum amount established by the Internal Revenue Service. The annual contribution maximum for 2022 is based on the coverage option you elect: • Individual – $3,650 • Family (filing jointly) – $7,300 If you are 55 or older, you may make a yearly catch-up contribution of up to $1,000 to your HSA. If you turn 55 at any time during the plan year, you are eligible to make the catch-up contribution for the entire plan year. Qualified Expenses You can use your HSA for a wide range of qualified expenses, such as doctor’s visits, prescription drugs, lab work, medical equipment, contacts lenses, dental work, physical therapy…the list goes on! Refer to IRS Publication 502 for comprehensive guidelines. Important HSA Information • You will receive a debit card to manage your Health Savings Account. Keep in mind, available funds are limited to the balance in your HSA. • Always ask your health care provider to file claims with your medical provider so network discounts can be applied. 15
Dental Insurance
EMPLOYEE BENEFITS
Cigna | QCD ABOUT DENTAL Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and disease.
For full plan details, please visit your benefit website: www.gcisdbenefits.com
DPPO Plan Coverage is provided through Cigna. Two levels of benefits are available with the DPPO plan: in-network and out-ofnetwork. You may select the dental provider of your choice, but your level of coverage may vary based on the provider you see for services. You could pay more if you use an out-of-network provider. ID Cards You can request your dental ID card by contacting Cigna directly or go to www.mycigna.com and register/login to access your account. In addition, you can download the “MyCigna” app on your smartphone and access your id card right there on your phone. Group Number and carrier contact information on page 3. How to Find an In-network Dentist To search for a dentist on Cigna.com, visit the site and click “Find a Doctor, Dentist or Facility.” Follow the prompts on screen and when asked to choose your plan, select “DPPO/EPO > Total Cigna DPPO.” Or call Cigna for assistance, group number and contact information on page 3. Claims In-network dentists will file claims on your behalf. Claim Reimbursement forms on benefits website, group number and carrier contact on page 3.
Medical Monthly Premiums High PPO
Low PPO
QCD
Employee Only
$44.48
$25.92
$0.00
Employee + 1
$84.71
$49.35
$10.00
Employee and Family
$132.50
$77.28
$14.00
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Dental Insurance
EMPLOYEE BENEFITS
Cigna | QCD GCISD Cigna Dental Choice Plan Summary Please see plan documents for details and limitations High PPO Plan
Reimbursement Levels
Calendar Year Deductible Individual Family
In-Network ‘Total Cigna DPPO’
Out-of-Network
In-Network ‘Total Cigna DPPO’
Out-of-Network
Based on Contracted Fees
Maximum Reimbursable Charge, you may be balanced billed
Based on Contracted Fees
Maximum Allowable Charge, you may be balanced billed.
$50 $150
$50 $150
$50 $150
$50 $150
Calendar Year Benefit Maximum Per Individual
Preventive and Diagnostic Care Exams, cleanings, X-rays, fluoride treatments, sealants, space maintainers
Basic Restorative Care Fillings, minor oral surgery, Emergency Care to Relieve Pain
Major Restorative Care/Implants Crowns, dentures, bridges, periodontics, endodontics, implants
Orthodontia Children only to age 19
Orthodontia Lifetime Maximum
PPO Low Plan
$1000
$1000
Plan Pays
You Pay
Plan Pays
You Pay
100% No Deductible
No Charge
80% No Deductible
20% No Deductible
80% After Deductible
20% After Deductible
50% after deductible
50% after deductible
50% After Deductible
50% after deductible
50% after deductible
50% after deductible
50% No Deductible
$50% No Deductible
$50% No Deductible
$50% No Deductible
$1000
No Coverage
Discount Dental with QCD Not a dental insurance plan, QCD is a discount dental program which offers discounted services through QCD Affiliated Dentists. This program is provided to enrolled employees for $0 cost, one dependent may be added at $10 per month or family coverage is $14 per month. Need more information, please visit www.qcdofamerica.com or call 800-229-0304.
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Vision Insurance
EMPLOYEE BENEFITS
Superior Vision ABOUT VISION Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses.
For full plan details, please visit your benefit website: www.gcisdbenefits.com
Vision Coverage: Our vision plan provides quality care to help preserve your health and eyesight. In addition to identifying vision and eye problems, regular exams can detect certain medical issues such as diabetes and high cholesterol. You may seek care from any licensed optometrist, ophthalmologist or optician, but plan benefits offer better value if you use an in-network provider. Premium contributions are deducted from your paycheck on a pretax basis. Coverage is provided through Superior Vision.
How to Find a Vision Provider Visit www.superiorvision.com select “Find an Eye Care Professional”. Coverage Info is “Insurance Through Your Employer” then Choose Your Network “Superior National” or call 1 (800) 507-3800 for assistance. Group Number and additional Carrier information found on page 3.
Copays Exam Materials Contact Lens Fittings
$10 $25 $25
Exam Lenses • Single Vision • Bifocals • Trifocals • Scratch Coat (factory) Frames Contact Lens Fitting (standard)
Contacts In lieu of frames and lenses • Contact Lenses
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Services/Frequency Exam 12 months Frame 12 months Lenses 12 months Contacts / Lens Fitting 12 months In-Network You Pay after Co-Pays Covered in full
Monthly Premiums Employee Only Employee & Spouse Employee and Child(ren) Employee and Family Out-of-Network Reimbursement Up to $35 retail
$150 retail Allowance
Up to $32 retail Up to $46 retail Up to $61 retail Not covered Up to $81 retail
Covered in full
Not covered
$130 retail allowance
Up to $100 retail
Covered in full
$8.42 $16.10 $16.89 $24.92
Accident Insurance
EMPLOYEE BENEFITS
The Hartford ABOUT ACCIDENT Do you have kids playing sports, are you a weekend warrior, or maybe accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you.
For full plan details, please visit your benefit website: www.gcisdbenefits.com
With Accident insurance provided through The Hartford, you’ll receive cash benefits when injuries, medical treatment and/or services occur as the result of a covered accident. You can use the payment in any way you choose – from expenses not covered by your major medical plan to day-to-day costs of living such as the mortgage or utility bills. CLAIMS Claims forms available Benefit Website. Group number and carrier contact information is on page 3.
Employee Employee + Spouse Employee + Child(ren) Family
Accident Monthly Premiums Option 1 $5.48 $8.65 $8.95 $14.17
PLAN INFORMATION Coverage Type SAMPLE BENEFITS - refer to plan sheet for complete schedule EMERGENCY, HOSPITAL & TREATMENT CARE Accident Follow-Up Up to 3 visits per accident Acupuncture/Chiropractic Care/PT Up to 10 visits each per accident Ambulance – Air Once per accident Ambulance – Ground Once per accident Blood/Plasma/Platelets Once per accident Child Care Up to 30 days per accident while insured is confined Daily Hospital Confinement Up to 365 days per lifetime Daily ICU Confinement Up to 30 days per accident Diagnostic Exam Once per accident Emergency Dental Once per accident Emergency Room Once per accident Health Screening Benefit Once per year for each covered person Hospital Admission Once per accident Initial Physician Office Visit Once per accident Lodging Up to 30 nights per lifetime Medical Appliance Once per accident Rehabilitation Facility Up to 15 days per lifetime Transportation Up to 3 trips per accident Urgent Care Once per accident X-ray Once per accident
Option 2 $12.84 $20.25 $21.71 $34.06
OPTION 1 Off-job only
OPTION 2 Off-job only
OPTION 1 $50 $25 $600 $200 $150 $25 $100 $300 $100 Up to $150 $100 $50 $500 $50 $100 $50 $50 $200 $50 $50
OPTION 2 $100 $50 $1,200 $400 $300 $30 $300 $600 $300 Up to $450 $200 $50 $1,500 $100 $150 $150 $150 $500 $100 $75
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Disability Insurance The Hartford
EMPLOYEE BENEFITS
ABOUT DISABILITY Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
For full plan details, please visit your benefit website: www.gcisdbenefits.com
Disability insurance combines the features of a short-term and long-term disability plan into one policy. The coverage pays you a portion of your earnings if you cannot work because of a disabling illness or injury. The plan gives you the flexibility to choose a level of coverage to suit your need. This coverage is provided by The Hartford. CLAIMS: Call The Hartford Claims at 866-547-9124 to file a claim, group number on page 3. Injury (Days) *0 *14 *30 60 90 180
Elimination Period (Days) Sickness (Days) Monthly Increment of $200 *7 $6.96 *14 $6.16 *30 $5.44 60 $3.36 90 $2.50 180 $1.92
*If because of your disability you are hospital confined as inpatient, benefits begin on the first day of inpatient confinement.
IMPORTANT NOTES Effective Date: Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect. Benefit Amount: You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66 2/3% of your current monthly earnings. Earnings are defined in The Hartford’s contract with your employer. Elimination Period: You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Disability benefit payment. The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin. For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization. Definition of Disability: Disability is defined as The Hartford’s contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical conditions covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre20
Disability Insurance The Hartford
EMPLOYEE BENEFITS
disability earnings. One you have been disabled for 24 months, you must be prevented from performing one or more essential duties of any occupation, and as a result, your monthly earnings are 66 2/3% or less of your pre-disability earnings. Pre-Existing Condition Limitation: Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 6 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 6 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. If your disability is a result of a preexisting condition, the carrier will pay benefits for a maximum of 4 weeks. Maximum Benefit Duration: Benefit Duration is the maximum time for which the carrier will pay benefits for disability resulting from sickness or injury. Depending on the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on the Premium benefit option. Age Disabled Maximum Benefit Duration Prior to 63 To Normal Retirement Age or 48 months if greater Age 63 To Normal Retirement Age or 42 months if greater Age 64 36 months Age 65 30 months Age 66 27 months Age 67 24 months Age 68 21 months Age 69 and older 18 months General Exclusions: You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: • War or act of war (declared or not) • Military service for any country engaged in war or other armed conflict • The commission of, or attempt to commit a felony • An intentionally self-inflicted injury • Any case where your being engaged in an illegal occupation was a contributing cause to your disability • You must be under the regular care of a physician to receive benefits
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Cancer Insurance
EMPLOYEE BENEFITS
APL ABOUT CANCER 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.
For full plan details, please visit your benefit website: www.gcisdbenefits.com
Treatment for cancer is often lengthy and expensive. While your health insurance helps pay the medical expenses for cancer treatment, it does not cover the cost of non-medical expenses, such as out-of-town treatments, special diets, daily living and household upkeep. In addition to these non-medical expenses, you are responsible for paying your health plan deductibles and/or coinsurance. Cancer insurance through APL pays a benefit directly to you to help with expenses associated with cancer treatment. CLAIMS Claim form on Benefit website, group number and carrier contact information is on page 3. Monthly Premium Individual One Parent Two Parent
Level 1 $13.80 $19.10 $24.30
Level 1 + ICU Rider $17.10 $23.60 $31.20
Level 2 $29.90 $40.90 $51.90
Level 2 + ICU Rider $33.20 $45.40 $58.80
*Premium and amount of benefits provided vary dependent upon the level selected at time of application. **Total premium includes the policy and riders of the option selected. Pre-Existing Condition Limitations Apply, see plan documents on benefit website for details and limitations.
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Cancer Insurance APL Benefits Radiation Therapy/Chemotherapy/ Immunotherapy Benefit Hormone Therapy Benefit Surgical Schedule Benefit Anesthesia Benefit Hospital Confinement Benefit
Summary of Benefits Level 1 Base Plan $500 per calendar month of treatment
EMPLOYEE BENEFITS
Level 2 Base Plan $1,500 per calendar month of treatment
$50 per treatment, up to 12 per calendar year $50 per treatment, up to 12 per calendar year $1,600 max per operation; $15 per surgical $4,800 max per operation; $45 per surgical unit unit 25% of the amount paid for covered surgery 25% of the amount paid for covered surgery $100 per day 1-90 days; $100 per day, 91+ $300 per day 1-90 days; $300 per day, 91+ days days in lieu of other benefits in lieu of other benefits $100 per day in lieu of most other benefits $300 per day in lieu of most other benefits
US Government/Charity Hospital/ HMO Outpatient Hospital or Ambulatory $200 per day of surgery $600 per day of surgery Surgical Center Benefit Drugs & Medicine Benefit - Inpatient $150 per confinement $150 per confinement Drugs & Medicine Benefit $50 per prescription, up to $50 per cal month $50 per prescription, up to $150 per cal month Outpatient Transportation & Outpatient $0.50 per mile per round trip $0.50 per mile per round trip Lodging Benefit $100 per day, up to 100 days per calendar year $100 per day, up to 100 days per calendar year Family Member Transportation & $0.50 per mile per round trip $0.50 per mile per round trip Lodging Benefit $100 per day, up to 100 days per calendar year $100 per day, up to 100 days per calendar year Blood, Plasma & Platelets Benefit $150 per day, up to $7,500 per calendar year $250 per day, up to $12,500 per calendar year Bone Marrow/Stem Cell Transplant Autologous - $500 per calendar year Autologous - $1,500 per calendar year Non-Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year Experimental Treatment Benefit Pays as any non-experimental benefit Pays as any non-experimental benefit Attending Physician Benefit $30 per day of confinement $50 per day of confinement Surgical Prosthesis Benefit $1,000 per device (includes surgical fee); max 1 $3,000 per device (includes surgical fee); max 2 device per site, 2 lifetime max device per site, 2 lifetime max Hair Prosthesis Benefit $50 per hair prosthetic, 2 lifetime max $50 per hair prosthetic, 2 lifetime max Dread Disease Benefit $100 per day, 1-90 days of hospital $300 per day, 1-90 days of hospital confinement confinement Hospice Care Benefit $50 per day, $9,000 lifetime max $100 per day, $18,000 lifetime max Inpatient Special Nursing Services $150 per day of confinement $150 per day of confinement Ambulance Ground Benefit $200 per ground trip $200 per ground trip Ambulance Air Benefit $2,000 per air trip; up to 2 trips per hospital $2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air) confinement (any combination of ground/air) Extended Care Benefit $100 per day $300 per day Home Health Care Benefit $100 per day $300 per day Second & Third Surgical Opinions $300 per diagnosis; additional $300 if third opinion required Waiver of Premium Premium waived after 90 days of primary insured continuous total disability due to cancer Physical/Speech Therapy Benefit $25 per visit, up to 4 visits per calendar month, $1,000 lifetime max Riders Diagnostic Testing Benefit Rider $50; 1 person, per calendar year $50; 1 person, per calendar year Critical Illness Rider: Heart Attack/ $2,500 lump sum benefit $2,500 lump sum benefit Stroke Optional Benefit Rider Intensive Care Unit Rider Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission
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Life and AD&D
EMPLOYEE BENEFITS
Unum ABOUT LIFE AND AD&D Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered. For full plan details, please visit your benefit website: www.gcisdbenefits.com Life and Accidental Death and Dismemberment (AD&D) insurance through UNUM are important parts of your financial security, especially if others depend on you for support. With Life insurance, your beneficiary(ies) can use the coverage to pay off your debts, such as credit cards, mortgages and other final expenses. AD&D coverage provides specified benefits for a covered accidental bodily injury that causes dismemberment (e.g., the loss of a hand, foot or eye). In the event that death occurs from an accident, 100% of the AD&D benefit would be payable to your beneficiary(ies). As you grow older, your Life and AD&D coverage amount reduces 65% at age 65 and 50% at age 70. Claims: Please contact the GCISD Benefits office at 817-251-5577 for assistance in filing a life claim.
Basic Life and AD&D Basic Life and AD&D insurance are provided by GCISD at no cost to you. Eligible employees are automatically covered for 1 times annual earnings of term life insurance up to $50,000 without answering any health questions.
Voluntary Life and AD&D You may purchase additional Life and AD&D insurance for you and your eligible dependents. If you decline Voluntary Life and AD&D insurance when first eligible and wish to elect at a later date, Evidence of Insurability (EOI) – proof of good health – may be required before coverage is approved. You must elect Voluntary Life and AD&D coverage for yourself in order to elect coverage for your spouse or children. If you leave the district, you may be able to take your insurance with you.
Designating a Beneficiary A beneficiary is the person or entity you designate to receive the death benefits of your Life and AD&D insurance policies. You can name more than one beneficiary and you can change beneficiaries at any time. If you name more than one beneficiary, you must identify the share for each. 24
Life and AD&D Available Coverage • Increments of $10,000 up to 7 times salary, not to exceed Employee $500,000. • New Hire Guaranteed Issue $200,000 • Increments of $5,000 up to 100% of employee amount Spouse • New Hire Guaranteed Issue $25,000 • Birth to six months - $1,000 Child(ren) • Six months to age 26 - $10,000 Voluntary Group Life (per $10,000 in coverage ) Age Employee & Spouse 18-24 $0.48 25-29 $0.41 30-34 $0.50 35-39 $0.72 40-44 $1.01 45-49 $1.61 50-54 $2.42 55-59 $3.87 60-64 $5.54 65-69 $6.12 70-74 $8.47 75+ $17.91 Spouse rates based on Employee's age and can not exceed 100 % of the employees supplemental life amount. Child(ren) Voluntary Group Life - (per $10,000 in coverage ) 0-26 $2.00 AD&D (per $10,000) Employee Only $0.30 Family $0.50
Flexible Spending Account (FSA) NBS
EMPLOYEE BENEFITS
ABOUT FSA A Flexible Spending Account allows you to pay for eligible healthcare expenses with a pre-loaded debit card. You choose the amount to set aside from your paycheck every plan year, based on your employer’s annual plan limit. This money is use it or lose it within the plan year (unless your plan contains a $500 rollover or grace period provision).
For full plan details, please visit your benefit website: www.gcisdbenefits.com
HealthCare FSA A HealthCare FSA covers qualified medical, dental and vision expenses for you or your eligible dependents. You will receive a front-loaded debit card to use on eligible expenses, such as: • Dental and vision expenses • Medical deductibles and coinsurance • Prescription copays • Hearing aids and batteries If you enroll in a High Deductible Health Plan (HDHP) and contribute to a Health Savings Account (HSA) and FSA, your FSA becomes a Limited Purpose HealthCare FSA.
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Mail: PO Box 6980 West Jordan, UT 84084 Contact NBS: Call for Account Balance: 855-399-3035 Hours of Operation: 6:00 AM – 6:00 PM MST, M-F Phone: (800) 274-0503 Email: service@nbsbenefits.com
Dependent Care FSA
The Dependent Care FSA helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full time. You can use the account to pay for day care or baby sitter expenses for your children under age 13 and qualifying older dependents, Limited Purpose HealthCare FSA such as dependent parents. Reimbursement from your A Limited Purpose HealthCare FSA is available if you Dependent Care FSA is limited to the total amount enrolled in the TRS-ActiveCare HD (HDHP) and contribute deposited in your account at that time. To be eligible, you to an HSA. You can use a Limited Purpose Health Care FSA must be a single parent or you and your spouse must be to pay for eligible out-of-pocket dental and vision expenses employed outside the home, disabled or a full-time only, such as: student. • Dental and orthodontia care (i.e., fillings, X-rays and braces) Dependent Care FSA Guidelines • Vision care (e.g., eyeglasses, contact lenses and LASIK • Overnight camps are not eligible for reimbursement surgery) (only day camps can be considered). • If your child turns 13 midyear, you may only request How the HealthCare and Limited Purpose FSAs Work reimbursement for the part of the year when the child You can access the funds in your HealthCare or Limited is under age 13. Purpose FSA two ways: • You may request reimbursement for care of a spouse • Use your FSA debit card to pay for qualified expenses, or dependent of any age who spends at least eight doctor visits and prescription copays. hours a day in your home and is mentally or physically • Pay out-of-pocket and submit your receipts for incapable of self-care. reimbursement: • The dependent care provider cannot be your child Fax –844-438-1496 under age 19 or anyone claimed as a dependent on Email –service@nbsbenefits.com your income taxes. Online – my.nbsbnefits.com 25
Flexible Spending Account (FSA)
EMPLOYEE BENEFITS
NBS Important FSA Rules •
• • • •
The maximum per plan year you can contribute to a HealthCare or Limited Purpose FSA is $2,850. The maximum per plan year you can contribute to a Dependent Care FSA is $5,000 when filing jointly or head of household and $2,500 when married filing separately. You cannot change your election during the year unless you experience a Qualifying Life Event. Your HealthCare or Limited Purpose FSA debit card cannot be used to pay for dependent care expenses. You do not have to be enrolled in a medical plan to enroll in an FSA. Funds allocated to the HealthCare FSA, Limited Purpose FSA or Dependent Care FSA must be used during the plan year or are forfeited, this is known as the “use-it-or-lose it” rule.
Over-the-Counter Item Rule Reminder (OTC) Health care reform legislation requires that certain over-the-counter (OTC) items require a prescription to qualify as an eligible Health Care FSA expense. You will only need to obtain a one-time prescription for the current plan year. You can continue to purchase your regular prescription medications with your FSA debit card. However, the FSA debit card may not be used as payment for an OTC item, even when accompanied by a prescription. Flexible Spending Accounts Account Type
HealthCare FSA
Dependent Care FSA
Eligible Expenses Most medical, dental and vision care expenses that are not covered by your health plan (such as copayments, coinsurance, deductibles, eyeglasses and doctor-prescribed over-thecounter medications) Dependent care expenses (such as day care, after-school programs or elder care programs) so you and your spouse can work or attend school full-time
Annual Contribution Limits
Benefit
$2,850
Saves on eligible expenses not covered by insurance, reduces your taxable income
$5,000 single $2,500 if married and filing separate tax returns
Reduces your taxable income
FSAstore.Com FSAstore.com offers thousands of FSA-eligible products and services to purchase using your FSA Debit Card or any major credit card. Competitive pricing and free shipping on orders over $50 can save you up to 40% using your FSA pretax dollars. Shop directly at FSAstore.com or have your physician submit prescriptions (when required). The FSAstore.com Services Channel allows you to search a database of more than 300,000 health care providers for nearby eligible services, such as acupuncture and chiropractic care. The FSAstore.com Learning Center focuses on answering common questions and keeping you informed about changes to your FSA benefits.
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Notes
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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 Grapevine-Colleyville ISD 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 Grapevine-Colleyville ISD 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.GCISDBENEFITS.COM 28
