2022 - 2023 Plan Year
LITTLEFIELD ISD
BENEFIT GUIDE EFFECTIVE: 09/01/2022 - 8/31/2023 WWW.MYBENEFITSHUB.COM/LITTLEFIELDISD
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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 Health Savings Account (HSA) Telehealth Hospital Indemnity Dental Vision Disability Life and AD&D Cancer Accident Critical Illness Emergency Medical Transportation Flexible Spending Account (FSA)
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PG. 4
HOW TO ENROLL
PG. 6
SUMMARY PAGES
PG. 12
YOUR BENEFITS
Benefit Contact Information LITTLEFIELD ISD BENEFITS
TRS ACTIVECARE MEDICAL
TRS HMO MEDICAL
Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/littlefieldisd
BCBSTX (866) 355-5999 www.bcbstx.com/trsactivecare
Blue Essentials HMO (888) 378-1633 www.bcbstx.com/trshmo
HEALTH SAVINGS ACCOUNT
TELEHEALTH
HOSPITAL INDEMNITY
EECU (817) 882-0800 www.eecu.org
MDLive (888) 365-1663 www.members.mdlive.com/fbs/ landing_home
Symetra Group #12450000 (800) 796-3872 www.symetra.com/Pages/home.aspx
DENTAL
VISION
DISABILITY
Marsh & McLennan (806) 385-4150
Superior Vision Group #34810 (800) 507-3800 www.superiorvision.com
The Hartford Group #894492 (866) 547-9124 www.TheHartford.com
LIFE AND AD&D
CANCER
ACCIDENT
The Hartford Group #894492 (888) 563-1124 www.TheHartford.com
American Public Life (800) 256-8606 www.ampublic.com
Mutual of Omaha (800) 775-6000 www.mutualofomaha.com
CRITICAL ILLNESS
EMERGENCY TRANSPORTATION
FLEXIBLE SPENDING ACCOUNT (FSA)
UNUM Group #476090 011 (800) 635-5597 www.unum.com
MASA (800) 423-3226 www.masamts.com
Higginbotham (866) 419-3519 www.higginbotham.net
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All Your Benefits One App Employee benefits made easy through the FBS Benefits App! Text “FBS LITTLEFIELD” 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 #: FBSLITTLEFIELD
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Text
“FBS LITTLEFIELD”
to (800) 583-6908 OR SCAN
How to Log In 1
www.mybenefitshub.com/littlefieldisd
2
CLICK LOGIN
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ENTER USERNAME & PASSWORD Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. If you have six (6) or less characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: Last Name (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.
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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 Department within 31 days of your qualifying event and meet with your Benefit Department 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 31 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 benefit questions, you can contact your Benefits Department or you can call Financial Benefit Services at (866) 914-5202 for assistance.
Where can I find forms? For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/ littlefieldisd. 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 Littlefield ISD benefit website: www.mybenefitshub.com/littlefieldisd. 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.
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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
To age 26
Telehealth
To age 26
Dental
To age 26
Vision
To age 26
Life
To age 26
Critical Illness
To age 26
AD&D
To age 26
Individual Life
To age 26
Accident
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 Benefit Administrator to request a continuation of coverage. 8
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 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).
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 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).
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 $500 rollover provision.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
Description
FLIP TO FOR HSA INFORMATION
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PG. 19
FLIP TO FOR FSA INFORMATION
PG. 35
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.mybenefitshub.com/littlefieldisd
Total Monthly Premium
Employer Contribution
Employee Cost
TRS ActiveCare HD Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$380.00
$380.00
$0.00
$1,069.00
$600.00
$469.00
$682.00
$600.00
$82.00
$1,279.00
$600.00
$679.00
TRS ActiveCare 2 Employee Only
$1,013.00
$600.00
$413.00
Employee & Spouse
$2,402.00
$600.00
$1,802.00
Employee & Child(ren)
$1,507.00
$600.00
$907.00
Employee & Family
$2,841.00
$600.00
$2,241.00
TRS ActiveCare Primary Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$368.00
$368.00
$0.00
$1,038.00
$600.00
$438.00
$662.00
$600.00
$62.00
$1,242.00
$600.00
$642.00
TRS ActiveCare Primary+ Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$462.00
$462.00
$0.00
$1,130.00
$600.00
$530.00
$744.00
$600.00
$144.00
$1,421.00
$600.00
$821.00
West Texas Blue Essentials HMO Employee Only
$689.60
$600.00
$89.60
Employee & Spouse
$1,672.26
$600.00
$1,072.26
Employee & Child(ren)
$1,083.58
$600.00
$483.58
Employee & Family
$1,775.58
$600.00
$1,175.58
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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.mybenefitshub.com/littlefieldisd
Health Savings Account (HSA) A Health Savings Account (HSA) is more than a way to help you and your family cover health care costs – it is also a tax-exempt 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.
You decide whether to use the money in your account to pay for qualified expenses or let it grow for future use. 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. Opening an HSA If you meet the eligibility requirements, you may open an HSA administered by EECU. You will receive a debit card to manage your HSA account reimbursements. Keep in mind, available funds are limited to the balance in your HSA.
Important HSA Information • Always ask your health care provider to file claims with your medical provider so network discounts can be applied. You can pay the provider with your HSA debit card based on the Who is eligible? balance due after discount. You are eligible to open and contribute to an HSA if you are: • You, not your employer, are responsible for maintaining ALL • Enrolled in an HSA-eligible HDHP records and receipts for HSA reimbursements in the event of • Not covered by another plan that is not a qualified HDHP, an IRS audit. such as your spouse’s health plan • Not enrolled in a Health Care Flexible Spending Account, nor You may open an HSA at the financial institution of your choice, but only accounts opened through EECU are eligible for should your spouse be contributing towards a Health Care automatic payroll deduction and company contributions. Flexible Spending Account •
Not eligible to be claimed as a dependent on someone else’s How to Use your HSA Online/Mobile: Sign-in for 24/7 account access to check your tax return balance, pay bills and more. • Not enrolled in Medicare or TRICARE Call/Text: (817) 882-0800. EECU’s dedicated member service • Not receiving Veterans Administration benefits representatives are available to assist you with any • You can use the money in your HSA to pay for qualified questions. medical expenses now or in the future. You can also use HSA Their hours of operation are Monday-Friday from 8:00a.m.funds to pay health care expenses for your dependents, even 7:00p.m. CT, Saturday 9:00a.m. - 1:00 p.m. CT and closed on if they are not covered under your HDHP. Sunday. Maximum Contributions Lost/Stolen Debit Card: Call the 24/7 debit card hotline at Your HSA contributions may not exceed the annual maximum (800) 333-9934 amount established by the Internal Revenue Service. The annual Stop by a local EECU financial center for in-person assistance; contribution maximum for 2022 is based on the coverage option find EECU locations & service hours at www.eecu.org/locations. you elect: Health Savings Account (HSA) Individual $3,650.00 Family $7,300.00 19
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.mybenefitshub.com/littlefieldisd
Telehealth Alongside your medical coverage is access to quality telehealth services through MDLIVE. Connect anytime day or night with a board-certified doctor via your mobile device or computer. 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 a business trip, vacation or away from home Are unable to see your primary care physician
When to Use MDLIVE At a cost that is the same or less than a visit to your physician, use telehealth services for minor conditions such as: • • •
Sore throat Headache Stomachache
• • •
Cold Flu Allergies
• •
Fever Urinary tract infections
Do not use telemedicine for serious or life-threatening emergencies. Registration is Easy Register with MDLIVE so you are ready to use this valuable service when and where you need it. • • • •
Online – www.mdlive.com/fbs Phone – (888) 365-1663 Mobile – download the MDLIVE mobile app to your smartphone or mobile device Select –“MDLIVE as a benefit” and “FBS” as your Employer/Organization when registering your account.
Telehealth Employee and Family
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$10.00
Hospital Indemnity
EMPLOYEE BENEFITS
Symetra 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.mybenefitshub.com/littlefieldisd
Fixed-Payment Indemnity Policy
Low Plan
High Plan
$1,500 initial day, $200 day 2+, 30 Days pp/pcy1
$2,500 initial day, $200 day 2+, 30 Days pp/pcy1
$1,500 initial day, $400 day 2+, 30 Days pp/pcy
$2,500 initial day, $400 day 2+, 30 Days pp/pcy
Included Included Included Included Included Low Plan
Included Included Included Included Included High Plan
$24.23
$35.05
Employee + Children
$51.63 $39.72
$74.69 $57.45
Family
$71.89
$103.99
Inpatient Hospital Benefits 500 days per lifetime unless noted Hospital Confinement
Intensive Care Unit
Health Advocacy Services EAP+Work/Life Program Wellness Program Pharmacy Discount Program Survivor Benefit Monthly Premium Employee Employee + Spouse
1
pp/pcy=per person, per calendar year
Patient advocacy services are included at no additional cost. These services are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA 19462. This is not an insured benefit. EAP+Work/Life and Wellness Programs are included at no additional cost. These programs are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA 19462. This is not an insured benefit. These benefits are designed to be offered to those covered under a High-Deductible Health Plan ('HDHP') without the effect of disqualifying a participant from electing an HSA. Please consult with your Benefits Advisor to assist with determination that electing this limited benefit coverage is in fact permitted coverage under the rules applicable to an HSA. 21
Hospital Indemnity Symetra A Pharmacy Discount Program is included at no additional cost. This program is administered by a prescription benefit manager, OptumRx, 11900 W Lake Park Drive, Milwaukee, WI 53224. This discount program is not an insured benefit. Your plan design and applicable premium amount may include benefits provided under one or more group policies. The plan design has been made available as a complete package and you may not elect to enroll in any policy or benefit separately. If you would like cost details, please contact your company or the plan administrator, Select Benefits Administrators at (800) 497-3699 or symsba@symetra.com. Please refer to the Description of Benefits included in this packet for additional information on your benefits. Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Coverage is provided under generic policy form numbers SBC-00500, SBC-00535, and LGC10011 or LGC-9072. Inpatient Hospital Benefit Benefits are paid on the first day of a covered stay. ICU stays are included with the hospital stay benefit. Each facility has a calendar year maximum number of days as selected, 500 days per lifetime unless otherwise noted in the policy. Please refer to your Plan Summary for details.
EMPLOYEE BENEFITS NurseLine™ Direct access to a registered nurse 24/7 for non-urgent concerns. Medical Bill Saver™ Help negotiating with providers for medical and dental bills that are not covered by your insurance. EAP+Work/Life Licensed professional counselors and work/life specialists provide confidential, short-term help with personal, family and work-related issues. Wellness Program Unlimited access to highly trained wellness coaches by telephone, email or instant messaging. Includes a comprehensive, secure wellness website. Pharmacy Discount Program A discount from usual and customary drug charges will be given to the eligible person when prescriptions are purchased through a contracting pharmacy. Survivor Benefit If an employee dies while insured, any covered dependents will be extended benefits (except Dependent Life, Group Accident, and Critical Illness) without premium payments for up to two years after the employee's death. This is as long as the plan remains in force and the covered dependent meets the coverage requirements in the policy. If there is any conflict between this information and the policy issued, the terms of the policy will prevail.
Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, Health Advocacy Personalized assistance with a full range of health coverage reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance and insurance-related issues such as locating doctors and Company located at 777 108th Avenue NE, Suite 1200, other providers, scheduling appointments, getting cost Bellevue, WA 98004, and are not available in all U.S. states estimates and more. or any U.S. territory.
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Dental Insurance
EMPLOYEE BENEFITS
Marsh & McLennan 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.mybenefitshub.com/littlefieldisd
The purpose of the Littlefield ISD Dental Plan is to provide all eligible employees and their eligible dependents financial assistance by a partial reimbursement of noninsured expenses paid to a licensed dentist. Reimbursement is made for expenses incurred while the employee or dependent is covered under the Plan. All eligible employees and dependents electing coverage must complete an enrollment form. Those employees enrolling annually by August 31st will have coverage beginning September 1st through August 31st of each year. New hires after August 21st will be eligible the first day of the month following date of employment.
Cost of the Plan Littlefield ISD will pay the entire premium cost of the plan for each Full-time employee. Those employees electing to cover dependents will pay the following monthly charge: Dental Employee Only Employee & 1 Dependent Employee & Family
$0.00 $24.00 $40.00
this addition must be made by completing a new enrollment form and submitting it to the Plan Administrator.
Dependent Eligibility Eligible Dependents include your spouse and unmarried dependent children. Dependent children are to be defined as children from birth to age 26, step-children to age 26, foster children, and grandchildren. The dependent must be eligible for a deduction on the employee’s Federal Income Tax Return.
Plan Description Littlefield ISD Dental Benefit Plan will reimburse employees for dental expenses at the rate of 80% of the first $250.00 of covered treatment and 50% of the next $1,600.00. Maximum benefit reimbursed is limited to $1,000 per plan year participant. Covered expenses will be considered for all procedures performed by or under the direction of a dentist licensed by the state in which the service is performed. Reimbursement will be based on the date the procedure is performed.
Claim Procedure Employees electing to cover their dependents must do so on initial enrollment. Employees can enroll dependents only on the plan anniversary date after their initial enrollment. Once dependent coverage has been elected and payroll deduction authorized, coverage cannot be terminated (except on the plan anniversary date) without evidence of financial hardship or a change in dependent status (death, divorce, attainment of age 26). A newly acquired dependent may be added within 31 days of the time that the new dependent is acquired. Notification of
Our plan is not dental insurance, thus the claim process is simplified and reimbursement easier. Reimbursement request forms will be available. When the dentist has been paid for the service, submit the claim form along with an original paid receipt to the claims office and a reimbursement check will be returned to you. Requests for reimbursement must be made within 60 days from the time the dentist is paid.
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Dental Insurance
EMPLOYEE BENEFITS
Marsh & McLennan Orthodontic Claim Procedure
Eligible Dental Expenses
Orthodontic treatment is a continuing procedure and will only be reimbursed on a monthly basis. Reimbursement cannot be made in full for a procedure which is not complete. Reimbursement will be determined by the length of time a participant is scheduled to be in treatment. The normal reimbursement formula will then be calculated by dividing the total cost by the number of treatment months.
• • •
Limitations
Employees will be reimbursed 80% of the first $250 of covered expenses Employees will be reimbursed 50% of the next $1,600 of covered expenses • Requests for reimbursement must be made within sixty (60) days from the time the dentist is paid. • Orthodontic treatment will be reimbursed on a monthly basis. • Reimbursement will only be made for a completed treatment or procedure.
In the event an employee or dependent is covered under an insured dental plan, Littlefield ISD Dental Benefit Plan will make reimbursement for the charges not paid by the insurance plan according to our regular reimbursement formula. The insurance company explanation of benefits must accompany the request for reimbursement. Dental prescriptions for medications may be filed under the medical plan. Repair to natural teeth due to an accident may be filed under the medical plan.
Summary While it is not anticipated that Littlefield ISD will change any provisions in the Plan, the District reserves the right to amend the Plan or terminate the Plan at any time by giving 30 days prior notice to all participants. In the event of any dispute arising over the payment, lack of payment, or any other conflict that may arise, the District will control the manner in which the dispute is settled. Effective: September 1st
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Type A Expenses (Preventive or Diagnostic) Type B Expenses (Basic Restorative and Surgical) Type C Expenses (Major or Prosthodontic Procedures), and/or Type D (Orthodontic)
Maximum Calendar Year Reimbursement (all expenses) per Individual $1,000
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.mybenefitshub.com/littlefieldisd
Vision Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
$6.88 $13.75 $15.74 $24.26
Copays Exam Materials1 Contact lens fitting (standard & specialty)
$10 $25 $0
Benefits through Superior National network In-Network Out-of-Network Exam (ophthalmologist) Covered in full Up to $42 retail Exam (optometrist) Covered in full Up to $37 retail Frames $130 retail allowance Up to $52 retail Contact lens fitting (standard2) Covered in full Not covered 2 Contact lens fitting (specialty ) $50 retail allowance Not covered Lenses (standard) per pair Single vision Covered in full Up to $26 retail Bifocal Covered in full Up to $34 retail Trifocal Covered in full Up to $50 retail Progressives lens upgrade See description3 Up to $50 retail 4 Contact lenses $130 retail allowance Up to $100 retail
Discount features
Services/Frequency Exam 12 months Frame 12 months Contact lens fitting 12 months Lenses 12 months 12 months Contact lenses Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses. 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4 Contact lenses are in lieu of eyeglass lenses and frames benefit
Refractive surgery
Look for providers in the provider directory who accept discounts, Superior Vision has a nationwide network of independent as some do not; please verify their services and discounts (range refractive surgeons and partnerships with leading LASIK networks from 10%-30%) prior to service as they vary. who offer members a discount. These discounts range from 10%50%, and are the best possible discounts available to Superior Discounts on covered materials Vision. Contact QualSught LASIK at (877) 201-3602 for more Frames: 20% off amount over allowance information. Conventional Contacts: 20% off amount over allowance How to Print your Vision ID Card Disposable contact: 10% off amount over allowance You can request your vision id card by contacting Superior Vision Discounts on non-covered exam, services, and materials directly at (800) 507-3800. You can also go to Exams, frames, and prescription lenses: 30% off retail www.superiorvision.com and register/login to access your Lens options, contacts, miscellaneous options: 20% off retail account by clicking on “Members” at the top of the page. You can Disposable contact lenses: 10% off retail also download the Superior Vision mobile app on your smart Retinal imaging: $39 maximum out-of-pocket phone. 25
Disability Insurance
EMPLOYEE BENEFITS
The Hartford 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.mybenefitshub.com/littlefieldisd
What is Educator Disability Income Insurance? Educator 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. You can purchase Disability Insurance through your employer. This highlight sheet is an overview of your Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.
Disability - per $100 in benefit Elimination Period Premium 0/7 $2.72 14/14 $2.66 30/30 $2.42 60/60 $2.10 90/90 $1.58
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 pre-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.
Eligibility You are eligible if you are an active employee who works at least 20 hours per week.
Enrollment You can enroll in coverage within 31 days of your date of hire or during your annual enrollment period.
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 this day your coverage takes effect.
Actively at Work You must be at work with your Employer on your regularly scheduled workday. One that day, you must be performing for wage or profit all your regular duties in the usual way and for your usual number of hours. Actively at Work shall mean you are able to report for work with your Employer, performing all the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.
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 26
Disability Insurance The Hartford
EMPLOYEE BENEFITS
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 you 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.
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 12 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 12 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 24 months before your disability begins. If your disability is a result of a pre-existing condition, we will pay benefits for a maximum of 4 weeks.
Mental Illness, Alcoholism and Substance Abuse You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism, and substance abuse for a total of 24 months for all disability periods during your lifetime.
Duration Any period that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24-month lifetime limit.
Partial Disability Partial Disability is covered provided you have at least a 20% loss of earnings and duties of your job.
Maximum Benefit Duration Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury. Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of the Premium benefit option.
Premium Option For the Premium benefit option – the table below applies to disabilities resulting from sickness or injury. Age Disabled Prior to 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older
Maximum Benefit Duration To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This Benefit Highlights Sheet explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this Benefit Highlights Sheet and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2020 The Hartford.
27
Life and AD&D
EMPLOYEE BENEFITS
The Hartford 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.mybenefitshub.com/littlefieldisd
Age Employee Spouse
Voluntary Group Life - per $10,000 Employee; $5,000 Spouse in coverage <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ $0.80 $0.90 $1.10 $1.30 $1.80 $2.80 $4.40 $7.00 $8.70 $14.90 $0.32 $0.37 $0.47 $0.57 $0.82 $1.32 $2.12 $3.42 $4.27 $7.37
Basic Life Coverage Provided to eligible employee of Littlefield ISD. Guaranteed coverage amount for Self Maximum coverage amount for Self AD&D coverage amount for Self Guaranteed coverage amount for Spouse Maximum coverage amount for Spouse AD&D coverage amount for Spouse Guaranteed coverage amount for dependent children to 26 years
Voluntary Group Life - Child(ren) 0-26 $1.78 Spouse rates based on Employee's age.
A cash benefit of $20,000 to your loved ones in the event of your death, plus a matching cash benefit if you die in an accident. $200,000 5 times your annual salary ($250,000 maximum in increments of $10,000) Equal to the life insurance amount chosen $50,000 50% of the employee coverage amount ($250,000 maximum in increments of $5,000) Equal to the life insurance amount chosen $10,000
Guaranteed Life and AD&D Insurance Coverage Amount Initial Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $200,000 without providing evidence of insurability. If you submitted evidence of insurability in the past and were declined for medical reasons, you may be required to submit evidence of insurability. If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense. Maximum Life Insurance Coverage Amount You can choose a coverage amount up to 5 times your annual salary ($500,000 maximum) with evidence of insurability. See the Evidence of Insurability page for details. Your coverage amount will reduce by 50% when you reach age 70. Guaranteed Spouse Life and AD&D Insurance Coverage Amount Initial Enrollment: When you are first offered this coverage, you can choose a coverage amount up to 50% of your coverage amount ($50,000 maximum) for your spouse without providing evidence of insurability. If you submitted evidence of insurability in the past and were declined for medical reasons, you may be required to submit evidence of insurability. If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense. Maximum Life Insurance Coverage Amount You can choose a coverage amount up to 50% of your coverage amount ($250,000 maximum) for your spouse with evidence of insurability. Dependent Children Coverage You can secure term life insurance for your dependent children when you choose coverage for yourself. Guaranteed Life Insurance Coverage Options $10,000
28
Cancer Insurance
EMPLOYEE BENEFITS
American Public Life 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.mybenefitshub.com/littlefieldisd
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 nonmedical expenses, you are responsible for paying your health plan deductibles and/or coinsurance. Cancer insurance through American Public Life helps pay for these direct and indirect treatment costs so you can focus on your health. Summary of Benefits Cancer Treatment Policy Benefits Radiation Therapy, Chemotherapy, Immunotherapy Maximum per 12-month period Hormone Therapy - Maximum of 12 treatments per calendar year Experimental Treatment Surgical Rider Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime Miscellaneous Care Rider Benefits Outpatient Special Nursing Services - Up to same number of Hospital Confinement days Hospital Confinement • Per day of Hospital Confinement (1-30 days) • Per day of Eligible Dependent Children (1-30 days) • Per day of Hospital Confinement (31+ days) • Per day for Eligible Dependent Children (31+ days) Outpatient Facility - Per day surgery is performed
Cancer Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Low $18.61 $33.36 $25.78 $38.10
High $31.24 $52.37 $39.60 $66.42
Plan 1 Level 1
Plan 2 Level 4
$10,000
$20,000
$50 per treatment
$50 per treatment
paid in same manner and under the same maximums as any other benefit Level 1 Level 3 $30 unit dollar amount Max $3,000 $45 unit dollar amount Max $4,500 per operation per operation 25% of amount paid for covered surgery $6,000 $9,000 $600 $900 $1,000 / $100
$2,000 / $200
Level 1
Level 2
$150 per day
$150 per day
$100 $200 $100 $200 $200
$100 $200 $200 $400 $200
Should you need to file a claim contact APL at (800) 256-8606 or online at www.ampublic.com.
29
Accident Insurance
EMPLOYEE BENEFITS
Mutual of Omaha 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.mybenefitshub.com/littlefieldisd
Eligibility Requirements You must be actively working a minimum of 20 hours per week to be eligible for coverage. Dependent Eligibility Requirements To be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself. Premium Payment Coverage Type Annual Benefit Maximum (ABM) Portability
Accident Employee Only
$8.31
$13.38
Employee and Spouse
$14.48
$23.29
Employee and Child(ren)
$18.59
$29.65
Employee and Family
$22.04
$35.74
The premiums for this insurance are paid in full by you. 24-hour (On and off-job) Not Included Included HIGH PLAN LOW PLAN Express Benefit $100 $75 Initial Care & Emergency1 – Most treatment / service required within 72 hours of accident; Once per accident per insured person Emergency Room $200 $150 Urgent Care Center $125 $100 Initial Physician Office Visit $100 $75 Ambulance Up to $1,500 Up to $1,000 Specified Injuries1,2 Fractures (Surgical / Non-surgical) Up to $6,000/Up to $3,000 Up to $5,000/Up to $2,500 Dislocations (Surgical / Non-surgical) Up to $9,000/Up to $4,500 Up to $6,000/Up to $3,000 Lacerations Up to $800 Up to $600 Burns Up to $15,000 Up to $10,000 Dental Up to $300 Up to $200 Hospital, Surgical & Diagnostic1,3 Admission $1,500 $1,000 Daily Confinement (Up to 365 days per accident) $300 per day $200 per day ICU Confinement (Up to 15 days per accident) $600 per day $400 per day Rehab. Facility Confinement (Up to 30 days per accident) $150 per day $100 per day Surgical Up to $2,000 Up to $1,500 Diagnostic Up to $300 Up to $200 Follow-Up Care1 – Treatment / service required within 365 days of accident; Medical device is once per accident per insured person Physician Follow-Up Office Visit $100; Up to 6 per accident $75; Up to 6 per accident Therapy Services $50; Up to 6 per accident $25; Up to 6 per accident Medical Device $200 $100 Prosthetic Device(s) $1,000; Up to 2 per accident $750; Up to 2 per accident 30
Accident Insurance Mutual of Omaha
EMPLOYEE BENEFITS
Additional Benefits1 – Benefits are payable within 365 days of accident Transportation (Up to 3 trips per accident) $450 per trip $300 per trip Lodging (Up to 30 nights per accident) $150 per night $125 per night Childcare (Up to 30 days per accident) $30 per day $20 per day Catastrophic Benefits1,4 – Benefits are payable within 365 days of accident: Once per accident per insured person You: $50,000 You: $25,000 Principal Sum (PS) Spouse: $25,000 Spouse: $10,000 Child(ren): $10,000 Child(ren): $5,000 Common Carrier Accidental Death 300% of PS Transportation of Remains Up to $5,000 Dismemberment & Paralysis Up to 100% of PS Reasonable Modifications Up to 10% of PS Coma 25% of PS 50% of PS 1
Additional limitations apply as described in the certificate. Fractures and dislocations require treatment within 90 days of accident, burns and lacerations within 72 hours of an accident, and dental care within 30 days. If an insured person sustains both a fracture and dislocation as the result of the same accident, the maximum amount payable is up to 200% of the amount payable for the injury with the highest applicable benefit amount. 3 Daily confinement must begin with 90 days of accident and ICU confinement within 30 days. Surgical treatment timeframes vary. If applicable, diagnostic services must be received within 90 days of accident. Except for confinement benefits, most benefits are payable once per accident per insured person. If any surgery occurs concurrently with an open reduction for a fracture or dislocation of the same bone or joint as a result of the same accident, only the highest applicable benefit is payable. 4 The principal sum for you and your spouse reduces by 50% when you reach the age of 70. 2
Who is eligible for this insurance? You must be actively working (performing all normal duties of your job) at least 20 hours per week and be under age 80 Your dependent(s) must be performing normal activities and not be confined (at home or in a hospital / care facility) and any child (ren) must be under age 26 Can I insure my domestic partner or civil union partner? Any reference to “spouse” includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable federal law, state law, or law of the country, city or local government in your jurisdiction of residence. What is the “Express Benefit”? This benefit is payable upon notification of an accident in which an insured person is injured. It can be paid in a short time frame with minimal information (compared to a typical claim). Can I take this insurance with me if I change jobs / am no longer a member of this group? In the event this insurance ends due to a change in your employment / membership status with the group, or for certain other reasons, you or your insured spouse have the right to continue this insurance under the Portability provision, subject to certain conditions. When does this insurance end? Insurance will end on the last day of the month in which an insured person no longer satisfies the applicable eligibility conditions, or when you reach the age of 80. Additional circumstances under which insurance will end are described in the certificate. Are there any exclusions or limitations? The benefits payable are based on the insurance in effect on the date of the covered accident, subject to the definitions, limitations, exclusions and other provisions of the policy. The exclusions and limitations are summarized in the outline of coverage and detailed in the certificate. Please contact your benefits administrator for a copy of the outline of coverage or if you have questions prior to enrolling. This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the plan's benefits, exclusions, limitations and reductions. Should there be any discrepancy between the certificate booklet and this summary, the certificate booklet will prevail. Availability of benefits is subject to final acceptance and approval of the group application by the underwriting company. Accident insurance is underwritten by United of Omaha Life Insurance Company, 3300 Mutual of Omaha Plaza, Omaha, NE 68175, 1 (800) 769-7159. United of Omaha Life Insurance Company is licensed nationwide, except in New York. Policy form number 7000GM-U-EZ 2010. This policy provides accident insurance only. It does not provide basic hospital, basic medical or major medical insurance. It is not a Medicare supplement policy. The insurance is designed to pay you a fixed dollar amount regardless of the amount any provider charges. 31
Critical Illness Insurance
EMPLOYEE BENEFITS
UNUM ABOUT CRITICAL ILLNESS Critical illness insurance can be used towards medical or other expenses. It provides a lump sum benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke. The money can also be used for non-medical costs related to the illness, including transportation, child care, etc.
For full plan details, please visit your benefit website: www.mybenefitshub.com/littlefieldisd Who is eligible for this coverage? All employees in active employment in the United States working at least 20 hours per week and their eligible spouses and children (up to age 26 regardless of student or marital status).
Can I be denied coverage? Coverage is guarantee issue.
What are the Critical Illness coverage amounts? For Employee: One of the following choices $10,000, $20,000 or $30,000 For your Spouse and Children: 100% of employee coverage amount
When is coverage effective? Please see your Plan Administrator for your effective date of coverage. 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. 32
Employee <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Critical Illness $10,000.00 $20,000.00 $3.08 $4.28 $3.38 $4.88 $3.88 $5.88 $4.68 $7.48 $5.58 $9.28 $7.18 $12.48 $9.18 $16.48 $11.28 $20.68 $15.78 $29.68 $23.88 $45.88 $42.88 $83.88 $72.58 $143.28 $123.88 $245.88 $225.58 $449.28
What critical illness conditions are covered? Critical Illnesses Coronary Artery Disease (major) Coronary Artery Disease (minor) End Stage Renal (Kidney) Failure Heart Attack (Myocardial Infarction) Major Organ Failure Requiring Transplant Stroke Supplemental Critical Illnesses Benign Brain Tumor Coma Loss of Hearing Loss of Sight Loss of Speech Infectious Disease Occupational Human Immunodeficiency Virus (HIV) or Hepatitis Permanent Paralysis
$30,000.00 $5.48 $6.38 $7.88 $10.28 $12.98 $17.78 $23.78 $30.08 $43.58 $67.88 $124.88 $213.98 $367.88 $672.98
Percentage of Coverage Amount 50% 10% 100% 100% 100% 100% 100% 100% 100% 100% 100% 25% 100% 100%
Critical Illness Insurance
EMPLOYEE BENEFITS
UNUM What critical illness conditions are covered? Progressive Diseases Amyotrophic Lateral Sclerosis (ALS) Dementia (including Alzheimer’s Disease) Functional Loss Multiple Sclerosis (MS) Additional Critical Illnesses for your Children Cerebral Palsy Cleft Lip or Palate Cystic Fibrosis Down Syndrome Spina Bifida
Percentage of Coverage Amount 100% 100% 100% 100% 100% 100% 100% 100% 100%
Covered Condition Benefit The covered condition benefit is payable once per covered condition per insured. Unum will pay a covered condition benefit for a different covered condition if: • the new covered condition is medically unrelated to the first covered condition; or • the dates of diagnosis are separated by more than 180 days
Reoccurring Condition Benefit We will pay the reoccurring condition benefit for the diagnosis of the same covered condition if the covered condition benefit was previously paid, and the new date of diagnosis is more than 180 days after the prior date of diagnosis. The benefit amount for any reoccurring condition benefit is 100% of the percentage of coverage amount for that condition.
The following Covered Conditions are eligible for a reoccurring condition benefit: • • • • • • • •
Benign Brain Tumor Coma Coronary Artery Disease (Major) Coronary Artery Disease (Minor) End Stage Renal (Kidney) Failure Heart Attack (Myocardial Infraction) Major Organ Failure Requiring Transplant Stroke
Are wellness screenings covered? Each insured is eligible to receive one Be Well Benefit per calendar year. The Be Well Benefit Amount for covered members is $50.
Be Well Screenings include tests for the following:
• Cholesterol • diabetes • cancer • cardiovascular function. They also include imaging studies, immunizations, and annual examinations by a Physician. See certificate for details.
Are there any exclusions or limitations? We will not pay benefits for a claim that is caused by, contributed to by, or occurs because of any of the following: • committing or attempting to commit a felony; • being engaged in an illegal occupation or activity; • injuring oneself intentionally or attempting or committing suicide, whether sane or not; • active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, injury as an innocent bystander, or Injury for self-defense; • participating in war or any act of war, whether declared or undeclared; • combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations; • voluntary use of or treatment for voluntary use of any prescription or non- prescription drug, alcohol, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s Physician; • being intoxicated; and • a Date of Diagnosis that occurs while an Insured is legally incarcerated in a penal or correctional institution. • Additionally, no benefits will be paid for a Date of Diagnosis that occurs prior to the coverage effective date. 33
Emergency Medical Transport MASA
EMPLOYEE BENEFITS
ABOUT MEDICAL TRANSPORT Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It can include emergency transportation via ground ambulance, air ambulance and helicopter, depending on the plan.
For full plan details, please visit your benefit website: www.mybenefitshub.com/littlefieldisd
A MASA MTS Membership provides the ultimate peace of mind Emergency Transportation at an affordable rate for emergency ground and air Emergent Plus Platinum transportation service within the United States and Canada, Employee and Family $14.00 $39.00 regardless of whether the provider is in or out of a given group healthcare benefits network. After the group health plan pays its portion, MASA MTS works with providers to deliver our members’ $0 in out-of-pocket costs for emergency transport. Emergent Air Transportation In the event of a serious medical emergency, Members have access to emergency air transportation into a medical facility or between medical facilities. Emergent Ground Transportation In the event of a serious medical emergency, Members have access to emergency ground transportation into a medical facility or between medical facilities. Non-Emergency Inter-Facility Transportation In the event that a member is in stable condition in a medical facility but requires a heightened level of care that is not available at their current medical facility, Members have access to nonemergency air or ground transportation between medical facilities. Repatriation/Recuperation Suppose you or a family member is hospitalized more than 100-miles from your home. In that case, you have benefit coverage for air or ground medical transportation into a medical facility closer to your home for recuperation. Should you need assistance with a claim contact MASA at (800) 643-9023.
Emergency Air Transportation Emergent Ground Transportation Non-Emergency Inter-Facility Transportation Repatriation/Recuperation Escort Transportation Visitor Transportation Return Transportation Mortal Remains Transportation Minor Return Organ Retrieval/Organ Recipient Transportation Vehicle Return Pet Return Worldwide Coverage 34
Emergent Plus Membership ✓ ✓ ✓ ✓
Platinum Membership ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Flexible Spending Account (FSA) Higginbotham
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.mybenefitshub.com/littlefieldisd Health Care FSA The Health Care FSA covers qualified medical, dental and vision expenses for you or your eligible dependents. You may contribute up to $2,850 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include: • Dental and vision expenses • Medical deductibles and coinsurance • Prescription copays Hearing aids and batteries You may not contribute to a Health Care FSA if you enrolled in a High Deductible Health Plan (HDHP) and contribute to a Health Savings Account (HSA).
Overnight camps are not eligible for reimbursement (only day camps can be considered). If your child turns 13 mid-year, you may only request reimbursement for the part of the year when the child is under age 13. You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care. The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.
Important FSA Rules
The maximum per plan year you can contribute to a Health Care FSA is $2,850. The maximum per plan year you can contribute to Higginbotham Benefits Debit Card a Dependent Care FSA is $5,000 when filing jointly or head of The Higginbotham Benefits Debit Card gives you immediate household and $2,500 when married filing separately. access to funds in your Health Care FSA when you make a You cannot change your election during the year unless you purchase without needing to file a claim for reimbursement. If experience a Qualifying Life Event. you use the debit card to pay anything other than a copay Your Health Care FSA debit card can be used for health care amount, you will need to submit an itemized receipt or an expenses only. It cannot be used to pay for dependent care Explanation of Benefits (EOB). If you do not submit your receipts, expenses. you will receive a request for substantiation. You will have 60 The IRS has amended the “use it or lose it rule” to allow you to days to submit your receipts after receiving the request for carry-over up to $570 in your Health Care FSA into the next plan substantiation before your debit card is suspended. Check the year. The carry-over rule does not apply to your Dependent Care expiration date on your card to see when you should order a FSA. replacement card(s).
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 babysitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you must be a single parent, or you and your spouse must be employed outside the home, disabled or a full-time student.
Things to Consider Regarding the Dependent Care FSA
Over-the-Counter Item Rule Reminder 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.
Higginbotham Portal The Higginbotham Portal provides information and resources to help you manage your FSAs. Access plan documents, letters and notices, forms, account 35
Flexible Spending Account (FSA) Higginbotham
EMPLOYEE BENEFITS
balances, contributions, and other plan information. • • • • •
Update your personal information Utilize Section 125 tax calculators Look up qualified expenses Submit claims Request a new or replacement Benefits Debit Card
Register on the Higginbotham Portal Visit https://flexservices.higginbotham.net and click Register. Follow the instructions and scroll down to enter your information. Enter your Employee ID, which is your Social Security number with no dashes or spaces. Follow the prompts to navigate the site. If you have any questions or concerns, contact Higginbotham: • • •
Phone – (866) 419-3519 Email – flexclaims@higginbotham.net Fax – (866) 419-3516
Account Type
Eligible Expenses
Flexible Spending Accounts Annual Contribution Limits
Benefit
Health Care FSA
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)
$2,850
Saves on eligible expenses not covered by insurance, reduces your taxable income
Dependent Care FSA
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
$5,000 single $2,500 if married and filing separate tax returns
Reduces your taxable income
Higginbotham Flex Mobile App Easily access your Health Care FSA on your smartphone or tablet with the Higginbotham mobile app. Search for Higginbotham in your mobile device’s app store and download as you would any other app. • • • •
View Accounts – Includes detailed account and balance information Card Activity – Account information SnapClaim – File a claim and upload receipt photos directly from your smartphone Manage Subscriptions – Set up email notifications to keep up-to-date on all account and Health Care FSA debit card activity
Log in using the same username and password you use to log in to the Higginbotham Portal. Note: You must register on the Higginbotham Portal to use the mobile app.
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2022 - 2022 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 Littlefield 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 Littlefield 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.MYBENEFITSHUB.COM/LITTLEFIELDISD 40
