SHALLOWATER ISD BENEFIT GUIDE EFFECTIVE: 09/01/2022 8/31/2023 WWW.MYBENEFITSHUB.COM/SHALLOWATERISD 2022 - 2023 PlanYear 1
Table of Contents FLIP TO... How to Enroll 4-5 Annual Benefit Enrollment 6-11 1. Annual Enrollment 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Helpful Definitions 8 4. Eligibility Requirements 9 5. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) 10 Medical 12-18 Dental 19-20 Vision 21 Cancer 22-23 Accident 24-25 Identity Theft 26 Disability 27-28 Life and AD&D 29-30 Flexible Spending Account (FSA) 31-32 Health Savings Account (HSA) 33 Hospital Indemnity 34-35 Critical Illness 36 Emergency Transportation 37 Telehealth 38 HOW TO ENROLLPG. 4 SUMMARYPAGESPG. 6 BENEFITSYOURPG. 12 2
SHALLOWATER ISD BENEFITS TRS ACTIVECARE MEDICAL TRS HMO MEDICAL Financial Benefit Services (800) 583 www.mybenefitshub.com/shallowaterisd6908 (866)BCBSTX355 www.bcbstx.com/trsactivecare5999 Blue Essentials (888) 378 www.bcbstx.com/trshmo1633 DENTAL VISION CANCER GroupCigna #3335912 (800) 244 6224 www.cigna.com Superior Vision Group #320250 (800) 507 3800 www.superiorvision.com American Public Life (800) 256 www.ampublic.com8606 ACCIDENT IDENTITY THEFT DISABILITY American Public Life (800) 256 www.ampublic.com8606 www.idwatchdog.com(800)IDWatchdog7743772 www.unum.com(866)GroupUNUM#1253606793054 LIFE AND AD&D FLEXIBLE SPENDING ACCOUNT (FSA) HEALTH SAVINGS ACCOUNT (HSA) GroupCigna #SGM 603455 (800) 244 www.cigna.com6224 www.higginbotham.net(866)Higginbotham4193519 (817)EECU 882 www.eecu.org0800 HOSPITAL INDEMNITY CRITICAL ILLNESS EMERGENCY TRANSPORTATION The www.thehartford.com(866)Hartford5474205 GroupVoya #69511 4CCI (888) 238 www.voya.com4840 (800)MASA423 www.masamts.com3226 TELEHEALTH MDLIVE (888) 465 1663 landing_homehttps://members.mdlive.com/fbs/ Benefit Contact Information 3
Employee benefits made easy through the FBS Benefits App! AllYour BenefitsOne App OR SCAN Text “FBS SISD” to (800) 583-6908 App Group #: FBSSISD Text “FBS SISD” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment: • Benefit Resources • Online Enrollment • Interactive Tools • And more! 4
1 www.mybenefitshub.com/shallowaterisd How to Log In 2 CLICK LOGIN 3 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. 5
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.
Annual Enrollment
Where can I find forms?
• 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.
• Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.
Annual Benefit Enrollment
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.
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For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/ shallowaterisd. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms Howsection.can I find a Network Provider?
New Hire Enrollment
SUMMARY PAGES
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.
For benefit summaries and claim forms, go to the Shallowater ISD benefit www.mybenefitshub.com/shallowaterisdwebsite:. 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, but there are no changes to the plan, you typically will not receive a new ID card each year.
• 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.
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.
Annual Benefit Enrollment CHANGES IN (CIS):STATUS QUALIFYING EVENTS
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.
SUMMARY PAGES
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 adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.
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. Judgment/Decree/Order
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.
Eligibility for Government Programs
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.
Gain/Loss EligibilityDependents'ofStatus
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.
Change in Status of Employment Affecting Coverage Eligibility
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Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of your qualifying event and meet with your Benefit Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
Change in Number of Tax Dependents
Marital Status
The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively at work and/or pre existing condition exclusion provisions do apply, as applicable by carrier.
Annual Enrollment
Guaranteed Coverage
Pre Existing Conditions
The amount you pay each plan year before the plan begins to pay covered expenses.
The period during which existing employees are given the opportunity to enroll in or change their current elections.
In Network
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.
The most an eligible or insured person can pay in co insurance for covered expenses.
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.
Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescription drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
SUMMARY PAGESHelpful Definitions 8
Plan Year September 1st through August 31st
Calendar Year
Actively at Work
Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider. Out of Pocket Maximum
Annual Deductible
Employee RequirementsEligibility
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 Office to request a continuation of coverage.
Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if 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.
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.
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
FSA/HSAeligibility.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 Potentialguidance.Dependent
Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.
Dependent RequirementsEligibility
Plan Dependent Eligibility Dental To age 26 Vision To age 26 Cancer To age 26 Accident To age 26 Group Term Life / AD&D To age 26 Individual Life To age 23 MedicalSpendingFlexible To age 26, IRS DependentLegalStatus DependentFlexible Spending To age 26, IRS Legal DependentStatus 9
Annual Benefit Enrollment
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
Disclaimer:eligibility. 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
SUMMARY PAGES
SUMMARY PAGESHSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223) Flexible Spending Account (FSA) (IRC Sec. 125) Description 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 Employee Employee Account Owner Individual Employer Underlying RequirementInsurance 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 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. Does the account earn interest? Yes No Portable? Yes, portable year to year and between jobs. No FLIP TO FOR HSA INFORMATION PG. 33 FLIP TO FOR FSA INFORMATION PG. 31 10
Notes 11
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/shallowaterisd Medical Insurance TRS EMPLOYEE BENEFITS Monthly Premium District Contribution Employee Cost TRS ActiveCare HD Employee Only $380.00 $225.00 $155.00 Employee & Spouse $1,069.00 $225.00 $844.00 Employee & Child(ren) $682.00 $225.00 $457.00 Employee & Family $1,279.00 $225.00 $1,054.00 TRS ActiveCare Primary Employee Only $368.00 $225.00 $143.00 Employee & Spouse $1,038.00 $225.00 $813.00 Employee & Child(ren) $662.00 $225.00 $437.00 Employee & Family $1,242.00 $225.00 $1,017.00 TRS ActiveCare Primary+ Employee Only $462.00 $225.00 $237.00 Employee & Spouse $1,130.00 $225.00 $905.00 Employee & Child(ren) $744.00 $225.00 $519.00 Employee & Family $1,421.00 $225.00 $1,196.00 TRS ActiveCare 2 Employee Only $1,013.00 $225.00 $788.00 Employee & Spouse $2,402.00 $225.00 $2,177.00 Employee & Child(ren) $1,507.00 $225.00 $1,282.00 Employee & Family $2,841.00 $225.00 $2,616.00 West Texas Blue Essentials HMO Employee Only $689.60 $225.00 $464.60 Employee & Spouse $1,672.26 $225.00 $1,447.26 Employee & Child(ren) $1,083.58 $225.00 $858.58 Employee & Family $1,775.58 $225.00 $1,550.58 12
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in the geographic area. The
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may balance bill up to their usual fees. Dental Low and High Employee Only $38.11 Employee and Spouse $76.20 Employee and Child(ren) $77.73 Employee and Family $115.84 19
reimburse
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 Fordisease.fullplan details, please visit your benefit website: www.mybenefitshub.com/shallowaterisd Dental Insurance Cigna EMPLOYEE BENEFITS High Plan Network Options In Network: Cigna DPPO Advantage Network Out of Network: See Non Network Reimbursement Reimbursement Levels Based on Contracted Fees Maximum Reimbursable Charge Policy Year Benefits Maximum Applies to: Class I, II, III & IX expenses $1,000 $1,000 Policy Year Deductible FamilyIndividual $150$50 $150$50 Benefit Highlights Plan Pays You Pay Plan Pays You Pay Class I: Diagnostic & Preventive Oral Prophylaxis:Evaluationsroutine cleanings X rays: routine X rays: non routine Fluoride SpaceSealants:ApplicationpertoothMaintainers:non orthodontic Emergency Care to Relieve Pain 100% No Deductible No Charge 100% No Deductible No Charge Class II: Basic Restorative Restorative: fillings Endodontics: minor and Periodontics:major minor and major Oral Surgery: minor and major Anesthesia: general and IV sedation Repairs: dentures 80% After Deductible 20% After Deductible 80% After Deductible 20% After Deductible Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Oral Surgery: all except simple extractions 50% After Deductible 50% After Deductible 50% After Deductible 50% After Deductible Class IV: CoverageOrthodontiaforDependent Children to age 19 Lifetime Benefits Maximum: $1,000 50% No Deductible 50% No Deductible 50% No Deductible 50% No Deductible Class IX: Implants 50% After Deductible 50% After Deductible 50% After Deductible 50% After Deductible
In Reimbursement:Network For services provided by a Cigna Dental PPO network dentist, Cigna Dental will the dentist according to a Fee Schedule or Discount Schedule. Non Reimbursement:Network For services provided by a non network dentist, Cigna Dental will reimburse according to the ReimbursableMaximumCharge. The MRC calculated at the 90th of all providers amounts dentist
percentile
Provision: Payment will be reduced by 50% for Class III services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.
LatetoTheMaximumwillnetworkForNonScheduledentistCignaDentalservicesInCarenetworkinorhttps://hcpdirectory.cigna.com/Visit:call(800)2446224tofindannetworkdentist.YourwillbeCignaDentalDHMO.NetworkReimbursement:ForprovidedbyaCignaPPOnetworkdentist,DentalwillreimbursetheaccordingtoaFeeorDiscountSchedule.NetworkReimbursement:servicesprovidedbyanondentist,CignaDentalreimburseaccordingtotheAllowableCharge.dentistmaybalancebilluptheirusualfees.EntrantLimitation
You can request your dental id card by contacting Cigna directly at (800) 244 6224 You can also 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. How do I find an In network Dentist?
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Low Plan Network Options In Network: Cigna DPPO Advantage Network Out of Network: See Non Network Reimbursement Reimbursement Levels Based on Contracted Fees Maximum Allowable Charge Policy Year Benefits Maximum Applies to: Class I, II, III & IX expenses $1,000 $1,000 Policy Year Deductible FamilyIndividual $150$50 $150$50 Benefit Highlights Plan Pays You Pay Plan Pays You Pay Class I: Diagnostic & Preventive Oral Prophylaxis:Evaluationsroutine cleanings X rays: SpaceSealants:FluorideroutineApplicationpertoothMaintainers:non orthodontic Emergency Care to Relieve Pain 100% No Deductible No Charge 100% No Deductible Any amount over the AllowableMaximumCharge Class II: Basic Restorative Restorative: fillings Oral Surgery: simple extractions only Anesthesia: general and IV sedation Repairs: Dentures Denture Relines, Rebases and Adjustments 100% After Deductible 0% After Deductible 100% After Deductible 0% After Deductible Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel/ resin Crowns: permanent cast and porcelain Bridges and Dentures Oral Surgery: all except simple extraction Anesthesia: general and IV sedation 60% After Deductible 40% After Deductible 60% After Deductible 40% After Deductible Class IX: Implants 60% After Deductible 40% After Deductible 60% After Deductible 40% After Deductible Dental Insurance Cigna EMPLOYEE BENEFITS DPPO Plan Two levels of benefits are available with the DPPO plan: in network and out of network. 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. How to Find a Dentist Visit https://hcpdirectory.cigna.com/ or call (800) 244 6224 to find an in network dentist. How to Request a New ID Card
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/shallowaterisd Vision Insurance Superior Vision EMPLOYEE BENEFITS Vision Services/frequencyCopays Employee Only $7.68 Exam $10 Exam 12 months Employee and Spouse $13.10 Materials1 $25 Frame 24 months Employee and Child(ren) $13.86 Contact lenses 12 months Employee and Family $20.79 Lenses 12 months Benefits through Superior Select Southwest Network In Network Out of Network Exam Covered in full Up to $35 retail Frames $125 retail allowance Up to $70 retail Lenses (standard) per pair Single vision Covered in full Up to $25 retail Bifocal Covered in full Up to $40 retail Trifocal Covered in full Up to $45 retail Progressives lens upgrade See description1 Up to $45 retail Contact lenses2 $120 retail allowance Up to $80 retail Medically Necessary Contact lenses $120 retail allowance Up to $150 retail Co pays apply to in network benefits; co pays for out of network visits are deducted from reimbursements 1 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 2 Contact lenses and related professional services (fitting, evaluation and follow up) are covered in lieu of eyeglass lenses and frames benefit. Discount features Non Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy. The National LASIK Network of laser vision correction providers, featuring LasikPlus, offers members special program pricing on services. The program pricing should be verified prior to service. How to Print your Vision ID Card: You can request your vision id card by contacting Superior Vision directly at (800) 507 3800. You can also go to www.superiorvision.com and register/login to access your account by clicking on “Members” at the top of the page. You can also download the Superior Vision mobile app on your smart phone. 21
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/shallowaterisd Cancer Insurance American Public Life EMPLOYEE BENEFITS Low Plan High Plan Cancer Treatment Policy Benefits Level 3 Level 4 Radiation Therapy, Chemotherapy, Immunotherapy Maximum per 12 month period $15,000 $20,000 Hormone Therapy Maximum of 12 treatments per calendar year $50 per treatment $50 per treatment Experimental Treatment paid in same manner and under the same maximums as any other benefit Surgical Rider Benefits Level 1 Level 4 Surgical $30 unit dollar amount Max $3,000 per operation $45 unit dollar amount Max $6,000 per operation Anesthesia 25% of amount paid for covered surgery Bone Marrow Transplant Maximum per lifetime $6,000 $12,000 Stem Cell Transplant Maximum per lifetime $600 $1,200 Prosthesis Surgical Implantation / Non Surgical (not Hair Piece) 1 device per site, per lifetime $1,000 / $100 $3,000 / $300 Miscellaneous Care Rider Benefits Level 4 Level 4 Cancer Treatment Center Evaluation or Consultation 1 per lifetime $750 $750 Evaluation or Consultation Travel and Lodging 1 per lifetime $350 $350 Second / Third Surgical Opinion per diagnosis of cancer $300 / $300 $300 / $300 Drugs and Medicine Inpatient / Outpatient (maximum $150 per month) $150 per confinement $50 per prescription $150 per confinement $50 per prescription Hair Piece (Wig) 1 per lifetime $150 $150 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 American Public Life helps pay for these direct and indirect treatment costs so you can focus on your health. Cancer Low High Employee Only $21.25 $34.30 Employee and Spouse $38.10 $61.40 Employee and Child(ren) $26.25 $42.30 Employee and Family $39.95 $64.48 22
Equipment
Medical Maximum of 1 per $150 $150
Special Nursing Services
Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year
Physical, $25 per / $1,000 $25 per visit / $1,000 $10,000
calendar year
Waiver of Premium Waive Premium Waive Premium Internal Cancer First Occurrence Rider Benefits Level 2 Level 4 Lump Sum Benefit Maximum 1 per Covered Person per lifetime $5,000
and Platelets
Cancer Insurance American Public Life EMPLOYEE BENEFITS
Special Nursing
Travel by bus, plane, or train
Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime $7,500 $15,000 Heart Attach/Stroke First Occurrence Rider Benefits Level 2 Level 4 Lump Sum Benefit Maximum 1 per Covered Person per lifetime $2,500 $2,500 Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime $3,750 $3,750 Hospital Intensive Care Unit Rider Benefits Intensive Care Unit $600 per day $600 per day Step Down Unit Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit $300 per day $300 per day Should you need to file a claim contact APL at (800) 256 8606 or online at www.ampublic.com 23
Outpatient Up to same number of Hospital Confinement days $150 per day $150 per day
visit
benefit
Travel by car Lodging up to a maximum of 100 days per calendar year actual coach fare or $0.75 per mile $0.75 per mile $100 per day actual coach fare or $0.75 per mile $0.75 per mile $100 per day
Travel by bus, plane, or train Travel by car Family Lodging up to a maximum of 100 days per calendar year actual coach fare or $0.75 per mile $0.75 per mile $100 per day actual coach fare or $0.75 per mile $0.75 per mile $100 per day
Confinement
Inpatient Services per day of Hospital $150 per day $150 per day
Miscellaneous Care Rider Benefits Level 4 Level 4
Transportation Maximum 12 trips per calendar year for all modes of transportation combined.
Ambulance
Family Transportation Maximum 12 trips per calendar year for all modes of transportation combined.
Ground / Air Maximum of 2 trips per Hospital Confinement for all modes of transportation combined $200 / $2,000 per trip $200 / $2,000 per trip
Blood, Plasma $300 per day $300 per day
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/shallowaterisd Accident Insurance American Public Life EMPLOYEE BENEFITS Summary of Benefits 24 Hour Plan 1 Plan 2 Emergency Treatment 1 Unit 2 Units Initial Treatment within 72 hours of a Covered Accident in Emergency Room $150 $300 Initial Treatment within 72 hours of a Covered Accident in Physician’s Office $50 $100 Initial Treatment after 72 hours but within 30 days after a Covered Accident $25 $50 Follow Up Treatment Maximum of 6 visits $25 $50 Major Diagnostic Screening (MRI) $100 $200 X Ray $25 $50 Emergency Dental Work Crown / Extraction $75 / $25 $150 / $50 Patient Care 1 Unit 2 Units Hospital Admission per admission $500 $1,000 Hospital Confinement per day Maximum of 365 days $100 $200 Intensive Care Unit Confinement per day Maximum of 15 days $200 $400 Step Down Unit Confinement per day Maximum of 15 days $150 $300 Rehabilitation Unit Confinement per day Maximum of 90 days $50 $100 Therapy Physical, Occupational or Speech per visit Maximum of 8 visits $25 $50 AccidentUnit 1 Unit 2 Employee Only $9.12 $14.72 Employee and Spouse $13.10 $22.34 Employee and Child(ren) $17.98 $31.70 Employee and Family $22.02 $39.44 24
Transportation & Lodging 1 Unit 1 Unit Ambulance Ground/Air
Prosthesis
Up to $30,000 Catastrophic Loss* Up
Blood, Plasma and Platelets
Tendons, Ligaments, Rotator Cuff
Concussion
Up to $1,500 Up to $3,000 Up to $1,200 Up to $2,400 $250 $500 Up to $187.50 Up to $350 Up to $12,500 Up to $25,000 Up to $6,250 Up to $12,500 $125 $250 Up to $62.50 Up to $125 $50 $100
Burns
Eye Injury
Lacerations
Skin Grafts
Exploratory Surgery without Repair
Coma Due to a Covered Accident
Dislocation*
Ruptured Disc or Torn Knee Cartilage 25% if occurs during first 12 months
Epidural Pain Management
Hernia 25% if occurs during first 12 months
Family Member Lodging & Meals per day Maximum of 30 days
$100 Accidental Death & Dismemberment 1 Unit 2 Units Accidental Death Common Carrier/Other*
Summary of Benefits 24 Hour Plan 1 Plan 2 Injuries & Treatment 1 Unit 2 Units Fractures*
Accidental Dismemberment*
Appliances
Up to $200 Up to $400 $25 $50 $62.50 $125 $62.50 $125 $25 $50 $125 $250 $25 $50 $2,500 $5,000 $400/$1,200 $400/1,200 $300 $300 $100 $100,000/$25,000 $200,000/$50,000 Up to $15,000 to
Internal Injuries
Transportation per round trip Maximum of 3 round trips
$30,000 Up to $60,000 Accident Insurance American Public Life EMPLOYEE BENEFITS *Amounts shown are for individuals; amounts for spouse and child(ren) may vary. Please refer to your Schedule of Benefits for details. ** Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase without notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application. Should you need to file a claim contact APL at (800) 256 8606 or online at www.ampublic.com. 25
ABOUT IDENTITY THEFT PROTECTION Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered. For full plan details, please visit your benefit website: www.mybenefitshub.com/shallowaterisd Identity Theft IDWatchdog EMPLOYEE BENEFITS Identity Theft Is Growing Better Protect You and Your Family Fraud continues to grow more complex. It is becoming harder for consumers and identity theft victims to manage the intricacies on their own. Fraudsters are taking advantage of consumers' increased digital dependence to steal personal and financial information doubling the amount of identity theft reports to the FTC in 2020. Easy & Affordable Identity Protection ID Watchdog helps warn you when your personal information is stolen and helps you better protect yourself and your family from identity fraud when stolen information is used for illicit gain. You’ll have greater peace of mind knowing you don’t have to face the complexities of identity theft alone. More for Families. Our family plan helps you better protect the identities of your loved ones of all ages. We offer more features that help protect minors than any other provider. Powerful Features Included in Both ID Watchdog Plans IDWatchdog is here for you 24/7/365. Reach our in house customer care team at (866) 513 1518. Control & Manage • Financial Accounts & Social Account Monitoring • Registered Sex Offender • Reporting • Customizable Alert Options • Equifax Blocked Inquiry Alerts • National Provider ID Alerts Monitor & Detect • Dark Web Monitoring • Data Breach Notifications • High Risk Transactions Monitoring • Subprime Loan Monitoring • Public Records Monitoring • USPS Change of Address Monitoring • Identity Profile Report • Credit Score Tracker Support & Restore • Fully Managed Resolution Services including Pre Existing Conditions • Online Resolution Tracker • Lost Wallet Vault & Assistance • Deceased Family Member Fraud Remediation • Credit Freeze Assistance Plan Specific Features 1B Platinum Credit Report Monitoring 1 Bureau 3 Bureau Credit Report(s)4 & VantageScore Credit Score(s) 1 Bureau Monthly 1 Bureau Daily & 3 Bureau Annually Credit Report Lock 1 Bureau Multi Bureau Identity Theft Insurance Up to $1 Million Up to $1 Million 401K/HSA Stolen Funds Reimbursement ✓ Subprime Loan Block within the monitored lending network ✓ Social Account Takeover Alerts ✓ Integrated Fraud Alerts ✓ Identity Theft 1B Employee $7.95 Employee and Family $14.95 26
Disability Insurance UNUM EMPLOYEE BENEFITS Who is eligible?
What if I am out of work when insurance goes into effect? Insurance will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. What is my monthly benefit amount?
For full plan details, please visit your benefit website: www.mybenefitshub.com/shallowaterisd
How can I apply for coverage?
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.
How long do I have to wait to receive benefits? The elimination period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits. You may choose an Elimination Period (injury/sickness) of 0/7, 14/14, 30/30, 60/60, 90/90, or 180/180 days. If because of your disability, you are hospital confined as an impatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (applies to Elimination Periods of 30 days or less. Disability per $100 in benefit Elimination Period 0/7
You are eligible for Disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.
$3.64 14/14 $3.08 30/30 $2.67 60/60 $2.18 90/90 $1.25 180/180 $0.89 27
To apply for coverage, complete your enrollment form by 9/1/2022. If you were hired after 9/1/2022, check with your plan administrator for your eligibility date, and complete your enrollment form within 31 days of that date.
You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $7,500.
Do I have to pay for coverage if I become disabled? After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving benefits. What is considered a pre existing condition? You have a pre existing condition if: You received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and The disability begins in the first 12 months after your effective date of coverage.
UNUM EMPLOYEE BENEFITS
• The date the policy or plan is cancelled
• The date you no longer are in an eligible group
You are disabled when Unum determines that due to your sickness or injury:
• You are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
• you are unable to perform the material and substantial duties of your regular occupation; and
Your coverage under the policy ends on the earliest of the following:
After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury:
Age at Disability Maximum Duration of Benefits Less than age 60 To age 65, but not less than 5 years Age 60 through 64 5 years Age 65 through 69 To age 70, but not less than 1 year Age 70 and over 1 year 28
Disability Insurance What is my Benefit Duration?
When would I be considered disabled?
Your duration of benefits is based on the following: When does my coverage end?
• you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.
The loss of a professional or occupational license or certification does not, in itself, constitute disability. You must be under the regular care of a physician. Unless the policy specifies otherwise, as part of the disability claims evaluation process, Unum will evaluate your occupation based on how it is normally performed in the national economy, not how work is performed for a specific employer, at a specific location, or in a specific region.
• You must be under the regular care of a physician in order to be considered disabled.
• The last day you are in active employment except as provided under the covered layoff or leave of absence provision.
• The last day of the period for which you made any required contributions
• The date your eligible group is no longer covered
Life and AD&D Cigna EMPLOYEE BENEFITS 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/shallowaterisd Basic and Voluntary Term Life Eligibility Active, full time Employees of the Employer regularly working a minimum of 20 hours per week. Eligibility Waiting Period No waiting period. Basic Term Life paid by your employer Employee Benefit Amount and Maximum $30,000 Benefit Reduction Schedule Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85. Voluntary Term Life paid by you Employee Benefit Amount Units of $10,000 Guaranteed Coverage Amount Lesser of 7 times annual compensation or $150,000 Maximum Lesser of 7 times annual compensation or $250,000 Benefit Reduction Schedule Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85. Spouse Spouse is eligible provided that you apply for and are approved for coverage for yourself. Benefit Amount Units of $5,000 Guaranteed Coverage Amount $75,000 Maximum The lesser of $100,000 or 50% of the Employee’s Voluntary Life Insurance Amount. Dependent Children Under age 19 (or under age 26 if they are full time students), as long as you apply for and are approved for coverage for yourself. Premium includes all eligible children. Maximum Per Child $10,000 Benefit Amount from birth to 6 months Benefit Amount from 6 months to 26 $10,000$500 Voluntary Group Life per $10,000 in coverage Age 18 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75+ Employee $0.60 $0.70 $0.90 $1.30 $2.10 $3.60 $5.60 $8.60 $15.60 $28.00 $46.00 Spouse $0.60 $0.70 $0.90 $1.30 $2.10 $3.60 $5.60 $8.60 $15.60 $28.00 $46.00 Voluntary Group Life Child(ren) $10,000 in coverage Age 0 26 $1.00 Spouse rates based on Employee's age. AD&D $10,000 in coverage Employee $0.20 Employee and Family $0.40 29
Guaranteed
Spouse Spouse is eligible provided that you apply for and are approved for coverage for yourself Maximum $250,000
Dependent Children Under age 19 (or under age 26 if they are full time students), as long as you apply for and are approved for coverage for yourself. Maximum $10,000 and AD&D Coverage for Voluntary Term Life Insurance Coverage Coverage Amount is the amount of coverage you can elect without answering any medical questions or taking a health exam. Coverage is only available during Initial Enrollment and other times as approved. If you apply for coverage that is above the Coverage Amount, or if you are applying for coverage after 31 days after you become eligible, you must fill out a Medical Evidence of Insurability form. All dependent child benefits are guaranteed issue.
Basic Accidental Death & Dismemberment (AD&D) paid by your employer Employee Benefit Amount and Maximum $30,000 Benefit Reduction Schedule Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85.
When Your Coverage Begins and Ends Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid.
Basic and Voluntary Accidental Death & Dismemberment (AD&D)
Continuation for Disability for Employees Aged 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer’s plan.
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Eligibility Active, full time Employees of the Employer regularly working a minimum of 20 hours per week.
Guaranteed
Life
Voluntary Accidental Death & Dismemberment (AD&D) paid by you Employee Benefit Amount Units of $10,000 Maximum $250,000 Benefit Reduction Schedule Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85.
Rehabilitation During a Period of Disability If the insurance company determines that you are a suitable candidate for rehabilitation, the insurance company may require you to participate in an assessment and rehabilitation plan, not to exceed 18 months. A rehabilitation plan may consist of educational, vocational or physical rehabilitation or may include modified work or work on a part time basis. If you refuse such assistance without good cause (a medical reason preventing participation, in whole or in part, in the rehabilitation plan), insurance under this plan will end.
Guaranteed
Cigna EMPLOYEE BENEFITS Guaranteed
Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage.
Portability If your employment is terminated and you are under age 70, you can continue your [employee paid] life insurance on a direct bill basis. Coverage may also be continued for your spouse/children. Premiums will increase at this time. Coverage can be continued to age 70, unless the insurance company terminates portability for all insured persons. Refer to your certificate for details.
Eligibility Waiting Period No waiting period.
Conversion If group life coverage ends (except due to nonpayment of premium), your employment is terminated, membership in an eligible class is terminated, or insurance coverage is reduced based on attained age, you can convert to an individual non term policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Dependents may convert their coverage as well. Premiums may change at this time, and terms of coverage will be subject to change.
Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and have insured your spouse or children, their premium is also waived.
Accelerated Death Benefit Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 50% of the Basic Term Life Insurance coverage amount in force and up to 50% of the Voluntary Term Life Insurance coverage amount in force to be paid to the insured. This benefit is payable only once in the insured's lifetime and will reduce the life insurance death benefit.
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.
• 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).
Health Care FSA
• Medical deductibles and coinsurance
Flexible Spending Account (FSA)
Dependent Care FSA
ABOUT FSA
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.
Higginbotham Benefits Debit Card
Things to Consider Regarding the Dependent 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:
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 grace period provision).
Overnight camps are not eligible for reimbursement (only day camps can be considered).
For full plan details, please visit your benefit website: www.mybenefitshub.com/shallowaterisd
Important FSA Rules
Your Health Care FSA debit card can be used for health care expenses only. It cannot be used to pay for dependent care expenses. Flexible Spending Accounts (FSA)
Higginbotham EMPLOYEE BENEFITS
• Dental and vision expenses
The Higginbotham Benefits Debit Card gives you immediate access to funds in your Health Care FSA when you make a purchase without needing to file a claim for reimbursement. If you use the debit card to pay anything other than a copay amount, you will need to submit an itemized receipt or an Explanation of Benefits (EOB). If you do not submit your receipts, you will receive a request for substantiation. You will have 60 days to submit your receipts after receiving the request for substantiation before your debit card is suspended. Check the expiration date on your card to see when you should order a replacement card(s).
Individual $2,850.00 Dependent Care $5,000.00
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
The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.
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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 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.
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 balances, contributions, and other plan information. Register on the Higginbotham Portal Visit https://flexservices.higginbotham.net and click Register. Follow the instructions and scroll down to enter your Enterinformation.yourEmployee 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 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. Flexible Spending Account (FSA) Higginbotham EMPLOYEE BENEFITS Flexible Spending Accounts Account Type Eligible Expenses 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 the counter medications) $2,850 Saves on eligible expenses not covered by insurance, reduces your taxable income CareDependentFSA 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 incometaxable • Update your personal information • Utilize Section 125 tax calculators • Look up qualified expenses • Submit claims • Request a new or replacement Benefits Debit Card 32
• Not receiving Veterans Administration benefits
• Family (filing jointly) $7,300
• You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit.
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. Who is eligible? You are eligible to open and contribute to an HSA if you are:
• Not enrolled in a Health Care Flexible Spending Account, nor should your spouse be contributing towards a Health Care Flexible Spending Account
You may open an HSA at the financial institution of your choice, but only accounts opened through EECU are eligible for automatic payroll deduction and company contributions.
• Enrolled in an HSA eligible HDHP
Health Savings Account (HSA) BENEFITS
Opening an 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.
• Individual $3,650
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.
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/shallowaterisd
• Not eligible to be claimed as a dependent on someone else’s tax return
• Not enrolled in Medicare or TRICARE
EECU EMPLOYEE
Important HSA Information
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.
• 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 balance due after discount.
How to Use your HSA Online/Mobile: Sign in for 24/7 account access to check your balance, pay bills and more. Call/Text: (817) 882 0800. EECU’s dedicated member service representatives are available to assist you with any questions. Their hours of operation are Monday Friday from 8:00a.m. 7:00p.m. CT, Saturday 9:00a.m. 1:00 p.m. CT and closed on Sunday. Lost/Stolen Debit Card: Call the 24/7 debit card hotline at (800) 333 Stop9934byalocal EECU financial center for in person assistance; find EECU locations & service hours at www.eecu.org/locations
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ABOUT HSA
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:
• 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 under your HDHP.
• Not covered by another plan that is not a qualified HDHP, such as your spouse’s health plan
ABOUT HOSPITAL INDEMNITY This is an affordable supplemental plan that pays you should you be in patient 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/shallowaterisd Hospital Indemnity The Hartford EMPLOYEE BENEFITS IS THIS COVERAGE HSA COMPATIBLE? If you (or any dependent(s)) currently participate in a Health Saving Account (HSA) or if you plan to do so in the future, you should be aware that the IRS limits the types of supplemental insurance you may have in addition to a HSA, while still maintaining the tax exempt status of the HSA. This plan design was designed to be compatible with Health Savings Accounts (HSAs). However, if you have or plan to open an HSA, please consult your tax and legal advisors to determine which supplemental benefits may be purchased by employees with an HSA. WHO IS ELIGIBLE? You, your spouse and child(ren) are eligible for coverage. Any child(ren) must be under age 26. Low High Coverage Type On and off job (24 hour) On and off job (24 hour) Covered Events Illness and injury Illness and injury HSA Compatible Yes Yes Benefits Low High HOSPITAL CARE2 First Day Hospital Confinement Up to 1 day per year $1,500 $2,500 Daily Hospital Confinement (Day 2+) Up to 30 days per year $100 $100 Daily ICU Confinement (Day 1+) Up to 30 days per year $150 $250 Value Added Services Low High Ability Assist®EAP2 24/7/365 access to help for financial, legal, or emotional issues Included Included HealthChampionSM2 Administrative & clinical support following serious illness or injury Included Included 2 For Hospital Care benefits, when an insured is eligible for more than one benefit in a single day, only the highest benefit will be paid Hospital IndemnityLow High Employee Only $23.26 $36.08 Employee and Spouse $43.12 $66.75 Employee and Child(ren) $40.58 $62.67 Employee and Family $63.31 $97.74 34
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Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances. This insurance coverage includes certain limitations and exclusions. The certificate details all provisions, limitations, and exclusions for this insurance coverage. A copy of the certificate can be obtained from your employer.
Hospital Indemnity
CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP?
The initial effective date of this coverage is September 1, 2019. Subject to any eligibility waiting period established by your employer, if you enroll for coverage prior to this date, insurance will become effective on this date. If you enroll for coverage after this date, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage).
This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered.
WHEN CAN I ENROLL?
You may enroll during any scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer.
The Hartford EMPLOYEE BENEFITS CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER?
Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.
Yes. Any reference to “spouse” includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law.
You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility), unless already insured with the prior carrier.
WHEN DOES THIS INSURANCE END?
WHEN DOES THIS INSURANCE BEGIN?
AM I GUARANTEED COVERAGE?
This insurance is guaranteed issue coverage it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.5
HOW DO I PAY FOR THIS INSURANCE?
Critical Illness What is Critical Insurance? Critical Illness Insurance pays a lump sum benefit if you are diagnosed with a covered illness or condition on or after your effective date of coverage. You have the option to elect Critical Illness insurance to meet your needs. Critical Illness insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirements of minimum essential coverage under the Affordable Care Act. Who is eligible for Critical Illness Insurance? Active employees working at least 15 hours per week, your spouse, and your child(ren) to age 26. Other features of Critical Illness Insurance include: Guaranteed issue: No medical questions or tests are required for Flexible:coverage.You can use the benefit payments for any purpose you Payrolllike. deductions: Premiums are paid through convenient payroll Portable:deductions.Ifyouleave your current employer, you can take your coverage with you.
Forstated.acomplete
and any riders. How
For full plan details, please visit your benefit website: www.mybenefitshub.com/shallowaterisd
benefit
For what critical illnesses and conditions are benefits available? Critical Illness Insurance provides a benefit for the following illnesses and conditions. Covered illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness Benefit amount unless otherwise description of your benefits, along with applicable conditions on benefit and see your certificate insurance can Critical Illness Insurance help? your Critical Illness Insurance could (coverage
determination, exclusions
ABOUT CRITICAL ILLNESS
of
amounts may vary): How to File a Claim: 1.www.voya.comClickcontact and services 2. Select Claims and then “start a claim” 3. Complete the questionnaire so that a custom claim form package can be generated for you. 4. Download your claim forms. 5. Fill out each form by the appropriate party. 6. Father additional supporting documents. 7. Submit your completed and signed forms and supporting documents. 8. Upload at www.voya.com 9. Click on the contact and services 10. Select “Upload a form” Mail and or Fax information provided on the top of your claim form package. For questions regarding the claims process, please call (888) 238 4840 Critical Illness ($10,000.00) Age Employee Spouse > 30 $3.00 $3.80 30 39 $3.80 $5.50 40 49 $7.40 $10.80 50 59 $13.70 $19.40 60 64 $20.20 $25.30 65 69 $27.40 $25.80 70+ $41.50 $46.60 • Heart attach • Stroke • Coronary artery bypass (25%) • Coma • Major organ failure • Permanent paralysis • End stage renal (kidney) failure • Medical expenses, such as deductibles and copays • Child care • Home healthcare costs • Mortgage payment/rent and home maintenance 36
limitations,
Insurance Voya EMPLOYEE BENEFITS
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.
Below are a few examples of how
be used
provisions,
Shouldrecuperation.youneedassistance
Emergent
Emergency TransportationEmergent+ Platinum Employee and Family $14.00 $39.00 37
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/shallowaterisd
A MASA MTS Membership provides the ultimate peace of mind at an affordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benefits network. If a member has a high deductible health plan that is compatible with a health savings account, benefits will become available under the MASA membership for expenses incurred for medical care (as defined under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfies the applicable statutory minimum deductible under IRC section 223(c) for high deductible health plan coverage that is compatible with a health savings account. 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. 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 non emergency 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 with a claim contact MASA at (800) 643 9023.
Emergent
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/shallowaterisd Telehealth MDLIVE EMPLOYEE BENEFITS 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 $10.00 38
Notes 39
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 Shallowater 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.
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WWW.MYBENEFITSHUB.COM/SHALLOWATERISD 2022 - 2022 PlanYear
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 Shallowater 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.
