ISD BENEFIT
09/01/2023
8/31/2024 WWW.MYBENEFITSHUB.COM/FORTWORTHISD 1
2023 - 2024 Plan Year FORT WORTH
GUIDE EFFECTIVE:
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SUMMARY PAGES PG. 6 YOUR BENEFITS PG. 11 HOW TO ENROLL PG. 4 Benefit Contact Information 3 How to Enroll 4-5 Annual Benefit Enrollment 6-10 1. Annual Enrollment 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Eligibility Requirements 8 4. Helpful Definitions 9 5. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) 10 Medical 11-18 Health Savings Account (HSA) 19 Flexible Spending Account (FSA) 20 Dental Indemnity - DPPO 21 Dental DHMO and Advantage 22-23 Vision 24 Long Term Disability 25 Cancer Insurance 26 Life and AD&D 27 Permanent Life 28 Accident Insurance 29 Legal Services 30 January Savings Plan 31 Medical Transportation 32 2
Table of Contents FLIP TO...
Benefit Contact Information
FWISD BENEFITS OFFICE
FLEXIBLE SPENDING ACCOUNT
HEALTH SAVINGS ACCOUNT (817) 814-2240
www.fwisd.org
Email: benefits@fwisd.org
FINANCIAL BENEFIT SERVICES
Financial Benefit Services (800) 583-6908
www.mybenefitshub.com/fortworthisd
TRS-ACTIVECARE MEDICAL
Blue Cross Blue Shield of Texas (866) 355-5999
www.bcbstx.com/trsactivecare
MEDICAL
Baylor, Scott & White HMO (800) 321-7947
www.trs.swhp.org
MEDICAL
Blue Essentials HMO (888) 378-1633
www.bcbstx.com/trshmo
Higginbotham
P: (866) 419-3519
F: (817) 882-9267
flexservices.higginbotham.net
DENTAL DHMO
Humana Group #573701 (800) 979-4760
www.humanadental.com
DENTAL INDEMNITY DPPO
MetLife Group #122673 (800) 438-6388
www.metlife.com
LEGAL SERVICES
Texas Legal (800) 252-9346
www.texaslegal.org
PERMANENT LIFE
Texas Life (817) 545-3900 ext. 102
www.texaslife.com
OPTIONAL LIFE AND AD&D DISABILITY
MetLife
Group #122673-1-G (800) 638-6420
www.metlife.com
The Hartford Group #395332 (866) 547-9124
www.thehartford.com/mybenefits
VISION CANCER
Humana
Group #573701 (866) 537-0229
www.humanavisioncare.com
American Public Life Group #18296 (800) 256-8606
www.ampublic.com
MEDICAL TRANSPORTATION ACCIDENT
MASA
Group #MLFWISD (800) 423-3226
www.masamts.com
CHUBB
Group #BKRC671 (866) 445-8874
www.combinedinsurance.com
EECU (817) 882-0800
www.eecu.org
DENTAL ADVANTAGE
Humana Group #573701 (800) 979-4760
www.humanadental.com
COBRA (DENTAL, VISION)
National Benefit Services (800) 274-0503
www.nbsbenefits.com
COBRA (TRS-ACTIVECARE MEDICAL)
bswift (833) 682-8972
COBRA (MEDICAL)
Baylor Scott & White HMOWageWorks/Conexis (877) 722-2667
403(B) PLAN / 457 PLAN
TCG Administrators (800) 943-9179
www.tcgservices.com
JANUARY SAVINGS PLAN
Fort Worth ISD Payroll Department (817) 814-2180
www.fwisd.org
HIGGINBOTHAM
Higginbotham (817) 347-7031
www.higginbotham.net
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Employee benefits made easy through the FBS Benefits App!
• Benefit Resources
• Online Enrollment
• Interactive Tools
• And more!
App Group #: FBSFWISD Text “FBS FWISD” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment:
OR SCAN Text “FBS FWISD” to (800) 583-6908
All Your BenefitsOne App
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1 www.mybenefitshub.com/fortworthisd
3 Select Login with Microsoft using your District Email and District Password. Log in to the ThebenefitsHUB using Microsoft, you will proceed through a multi-factor authentication process to establish a link between Microsoft and TheBenefitsHUB account.
How
Log In
to
CLICK LOGIN
5
2
Annual Benefit Enrollment
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 eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
Q&A
Who do I contact with Questions?
For supplemental benefit questions, you can contact your Benefits Department at (817) 814-2240 or you can call Financial Benefit Services at (866) 914-5202 for assistance.
Don’t Forget!
Where can I find forms?
For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/fortworthisd. 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 Fort Worth ISD benefit website: www.mybenefitshub. com/fortworthisd. 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.
• Login and complete your benefit enrollment from 07/17/23 - 8/17/2023
• Login assistance is available by calling the FWISD Benefits Department at (817) 814-2240.
• Enrollment assistance is available 7/31-8/17, M-F, 8-5 by calling the Higginbotham Call Center at (817) 710-8135.
• REQUIRED: Provide correct dependent social security numbers.
SUMMARY PAGES
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Annual Benefit Enrollment
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 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/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.
CHANGES IN STATUS (CIS): QUALIFYING EVENTS
Marital Status
Change in Number of Tax Dependents
Change in Status of Employment Affecting Coverage Eligibility
Gain/Loss of Dependents’ Eligibility Status
Judgment/ Decree/Order
Eligibility for Government Programs
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.
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.
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.
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
SUMMARY PAGES
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Annual Benefit Enrollment
Employee Eligibility Requirements
Medical and Supplemental Benefits: Employees who are active contributing TRS members are eligible for all benefits. Employees who are not active contributing TRS members are eligible to participate in TRS Active Care. Eligibility criteria may be found at https://www.fwisd.org/Page/2561. Benefits 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 2023 benefits become effective on September 1, 2023, you must be actively-atwork on September 1, 2023 to be eligible for your new benefits.
Dependent Eligibility Requirements
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.
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 FWISD Benefits Department, or contact the insurance carrier for additional information on spouse eligibility.
FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse’s FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance.
Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility.
Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee’s enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.
SUMMARY PAGES
PLAN MAXIMUM AGE Medical 26 Dental 26 Dental 26 Vision 26 Optional Life and AD&D 26 Individual Life 26 Medical Flex (FSA) IRS Dependent Dependent Care Under the age of 13 or qualified individual unable to care for themselves & claimed as a dependent on your taxes Accident 26 Health Savings Account IRS Dependent covered on your HDHP Cancer 26 Medical Transportation 26, Including disabled children 8
Helpful Definitions
Actively-at-Work
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 9/1/2023 please notify your benefits administrator.
Annual Enrollment
The period during which existing employees are given the opportunity to enroll in or change their current elections.
Annual Deductible
The amount you pay each plan year before the plan begins to pay covered expenses.
Calendar Year
January 1st through December 31st
Co-insurance
After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Guaranteed Coverage
The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or preexisting condition exclusion provisions do apply, as applicable by carrier.
In-Network
Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.
Out-of-Pocket Maximum
The most an eligible or insured person can pay in coinsurance for covered expenses.
Plan Year
September 1st through August 31st
Pre-Existing Conditions
Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
SUMMARY PAGES
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Description
Health Savings Account (HSA) (IRC Sec. 223)
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.
Flexible Spending Account (FSA) (IRC Sec. 125)
Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, taxfree. This also allows employees to pay for qualifying dependent care tax- free.
Permissible Use Of Funds
Cash-Outs of Unused Amounts (if no medical expenses)
Year-to-year rollover of account balance?
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).
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65). Not permitted
Yes, will roll over to use for subsequent year’s health coverage.
No. Remaining balances are available through 10/31/2024.
Does the account earn interest? Yes No
Portable? Yes, portable year-to-year and between jobs. No
TO FOR HSA INFORMATION FLIP TO FOR FSA INFORMATION PG. 19 PG. 20 SUMMARY PAGES
FLIP
HSA vs. FSA
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 $1,500 single (2023) $3,000 family (2023) N/A Maximum Contribution $3,850 single (2023) $7,750 family (2023) 55+ catch up +$1,000 $3,050 (2023)
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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: TRS ActiveCare
FORT WORTH INDEPENDENT SCHOOL DISTRICT TRS-ACTIVECARE PLAN RATES EFFECTIVE 09-01-2023 THROUGH 08-31-2024 TRS-ACTIVECARE PRIMARY EMPLOYEE COST TRSACTIVECARE HD EMPLOYEE COST TRS-ACTIVECARE PRIMARY + EMPLOYEE COST TRSACTIVECARE 2 EMPLOYEE COST CENTRAL AND NORTH TEXAS BAYLOR SCOTT & WHITE EMPLOYEE COST 12 Checks EMPLOYEE ONLY $130.00 $144.00 $210.00 $682.00 $265.96 EMPLOYEE AND SPOUSE $914.00 $952.00 $1,076.00 $2,071.00 $1,170.90 EMPLOYEE AND CHILD(REN) $453.00 $477.00 $589.00 $1,176.00 $629.68 EMPLOYEE AND FAMILY $1,237.00 $1,284.00 $1,455.00 $2,510.00 $1,397.86 SPOUSAL-BOTH EMPLOYEE OF FWISD $906.00 $953.00 $1,124.00 $2,179.00 $1,066.86 SPOUSAL-ONE EMPLOYEE OF FWISD AND ONE OTHER DISTRICT $453.00 $476.50 $562.00 $1,089.50 $533.43 18 Checks EMPLOYEE ONLY $86.67 $96.00 $140.00 $454.67 $177.31 EMPLOYEE AND SPOUSE $609.33 $634.67 $717.33 $1,380.67 $780.60 EMPLOYEE AND CHILD(REN) $302.00 $318.00 $392.67 $784.00 $419.79 EMPLOYEE AND FAMILY $824.67 $856.00 $970.00 $1,673.33 $931.91 SPOUSAL-BOTH EMPLOYEE OF FWISD $604.00 $635.33 $749.33 $1,452.67 $711.24 SPOUSAL-ONE EMPLOYEE OF FWISD AND ONE OTHER DISTRICT $302.00 $317.67 $374.67 $726.33 $355.62 24 Checks EMPLOYEE ONLY $65.00 $72.00 $105.00 $341.00 $132.98 EMPLOYEE AND SPOUSE $457.00 $476.00 $538.00 $1,035.50 $585.45 EMPLOYEE AND CHILD(REN) $226.50 $238.50 $294.50 $588.00 $314.84 EMPLOYEE AND FAMILY $618.50 $642.00 $727.50 $1,255.00 $698.93 SPOUSAL-BOTH EMPLOYEE OF FWISD $453.00 $476.50 $562.00 $1,089.50 $533.43 SPOUSAL-ONE EMPLOYEE OF FWISD AND ONE OTHER DISTRICT $226.50 $238.25 $281.00 $544.75 $266.72 EMPLOYEE BENEFITS 11
Medical Insurance TRS
Medical Insurance TRS EMPLOYEE BENEFITS TRS-ACTIVE CARE RATES FOR EMPLOYEES WHO DO NOT CONTRIBUTE TO TRS PLAN RATES EFFECTIVE 09-01-2023 THROUGH 08-31-2024 TRS-ACTIVECARE PRIMARY EMPLOYEE COST TRSACTIVECARE HD EMPLOYEE COST TRS-ACTIVECARE PRIMARY + EMPLOYEE COST TRSACTIVECARE 2 EMPLOYEE COST CENTRAL AND NORTH TEXAS BAYLOR SCOTT & WHITE EMPLOYEE COST 12 Checks EMPLOYEE ONLY $461.00 $541.00 $475.00 $1,013.00 $596.96 EMPLOYEE AND SPOUSE $1,245.00 $1,407.00 $1,283.00 $2,402.00 $1,501.90 EMPLOYEE AND CHILD(REN) $784.00 $920.00 $808.00 $1,507.00 $960.68 EMPLOYEE AND FAMILY $1,568.00 $1,786.00 $1,615.00 $2,841.00 $1,728.86 18 Checks EMPLOYEE ONLY $307.33 $360.67 $316.67 $675.33 $397.97 EMPLOYEE AND SPOUSE $830.00 $938.00 $855.33 $1,601.33 $1,001.27 EMPLOYEE AND CHILD(REN) $522.67 $613.33 $538.67 $1,004.67 $640.45 EMPLOYEE AND FAMILY $1,045.33 $1,190.67 $1,076.67 $1,894.00 $1,152.57 24 Checks EMPLOYEE ONLY $230.50 $270.50 $237.50 $506.50 $298.48 EMPLOYEE AND SPOUSE $622.50 $703.50 $641.50 $1,201.00 $750.95 EMPLOYEE AND CHILD(REN) $392.00 $460.00 $404.00 $753.50 $480.34 EMPLOYEE AND FAMILY $784.00 $893.00 $807.50 $1,420.50 $864.43 12
Where the west begins is where TRS-ActiveCare rides with you on your health care journey.
TRS-ActiveCare Plan Highlights 2023-24
Learn the Terms.
• Premium: The monthly amount you pay for health care coverage.
• Deductible: The annual amount for medical expenses you’re responsible to pay before your plan begins to pay its portion.
• Copay: The set amount you pay for a covered service at the time you receive it. The amount can vary by the type of service.
• Coinsurance: The portion you’re required to pay for services after you meet your deductible. It’s often a speci ed percentage of the costs; i.e. you pay 20% while the health care plan pays 80%.
• Out-of-Pocket Maximum: The maximum amount you pay each year for medical costs. After reaching the out-of-pocket maximum, the plan pays 100% of allowable charges for covered services. 13
762374.0523
Monthly Premiums Employee Only $461 $ $541 Employee and Spouse $1,245 $ $1,407 Employee and Children $784 $ $920 Employee and Family $1,568 $ $1,786 Total Premium Total Premium Your Premium
Premium Total Monthly Premium Your District and State Contributions Your Premium Ask your Bene ts Administrator for your district’s speci c premiums.
TRS-ActiveCare participants have three plan options. TRS-ActiveCare Primary TRS-ActiveCare Plan Summary • Lowest premium of all three plans • Copays for doctor visits before you meet your deductible • Statewide network • Primary Care Provider (PCP) referrals required to see specialists • Not compatible with a Health Savings Account (HSA) • No out-of-network coverage • Lower deductible than • Copays for many services • Higher premium • Statewide network • PCP referrals required • Not compatible with • No out-of-network
Cost*
healthy is easy with:
$0 preventive care
24/7 customer service • One-on-one health coaches • Weight loss programs • Nutrition programs • OviaTM pregnancy support • TRS Virtual Health • Mental health bene ts • And much more!
for all plans. See the bene ts guide for more details. Immediate Care Urgent Care $50 copay Emergency Care You pay 30% after deductible You TRS Virtual Health-RediMD (TM) $0 per medical consultation $0 TRS Virtual Health-Teladoc® $12 per medical consultation $12 2023-24 TRS-ActiveCare Plan Highlights Sept. 1, 2023 –New Rx Bene ts! • Express Scripts is your new pharmacy bene ts manager! CVS pharmacies and most of your preferred pharmacies and medication are still included. • Certain specialty drugs are still $0 through SaveOnSP. Doctor Visits Primary Care $30 copay Specialist $70 copay Plan Features Type of Coverage In-Network Coverage Only In-Network Individual/Family Deductible $2,500/$5,000 Coinsurance You pay 30% after deductible You Individual/Family Maximum Out of Pocket $7,500/$15,000 Network Statewide Network PCP Required Yes Prescription Drugs Drug Deductible Integrated with medical $200 deductible Generics (31-Day Supply/90-Day Supply)$15/$45 copay; $0 copay for certain generics Preferred You pay 30% after deductible You Non-preferred You pay 50% after deductible You Specialty (31-Day Max) $0 if SaveOnSP eligible; You pay 30% after deductible You Insulin Out-of-Pocket Costs$25 copay for 31-day supply; $75 for 61-90 day supply$25 copay for 31-day 14
How to Calculate Your Monthly
All
Wellness Bene ts at No Extra
Being
•
•
*Available
This plan is closed and not accepting new enrollees. If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan. $ $475 $ $ $1,283 $ $ $808 $ $ $1,615 $ Premium Total Premium Your Premium Your Premium Total Premium Your Premium $1,013 $ $2,402 $ $1,507 $ $2,841 $ Each includes a wide range of wellness bene ts. TRS-ActiveCare 2 • Closed to new enrollees • Current enrollees can choose to stay in plan • Lower deductible • Copays for many services and drugs • Nationwide network with out-of-network coverage • No requirement for PCPs or referrals TRS-ActiveCare Primary+ TRS-ActiveCare HD than the HD and Primary plans services and drugs required to see specialists with a Health Savings Account (HSA) coverage • Compatible with a Health Savings Account (HSA) • Nationwide network with out-of-network coverage • No requirement for PCPs or referrals • Must meet your deductible before plan pays for non-preventive care $50 copay You pay 30% after deductibleYou pay 50% after deductible You pay 20% after deductible You pay 30% after deductible $0 per medical consultation $30 per medical consultation $12 per medical consultation $42 per medical consultation $50 copay You pay 40% after deductible You pay a $250 copay plus 20% after deductible $0 per medical consultation $12 per medical consultation Aug. 31, 2024 $15 copay You pay 30% after deductibleYou pay 50% after deductible $70 copay You pay 30% after deductibleYou pay 50% after deductible $30 copay You pay 40% after deductible $70 copay You pay 40% after deductible In-Network Coverage Only In-Network Out-of-Network $1,200/$2,400 $3,000/$6,000 $5,500/$11,000 You pay 20% after deductible You pay 30% after deductibleYou pay 50% after deductible $6,900/$13,800 $7,500/$15,000 $20,250/$40,500 Statewide Network Nationwide Network Yes No In-Network Out-of-Network $1,000/$3,000 $2,000/$6,000 You pay 20% after deductibleYou pay 40% after deductible $7,900/$15,800 $23,700/$47,400 Nationwide Network No deductible per participant (brand drugs only) Integrated with medical $15/$45 copay You pay 20% after deductible; $0 coinsurance for certain generics You pay 25% after deductible You pay 25% after deductible You pay 50% after deductible You pay 50% after deductible $0 if SaveOnSP eligible; You pay 30% after deductible You pay 20% after deductible 31-day supply; $75 for 61-90 day supply You pay 25% after deductible $200 brand deductible $20/$45 copay You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max) You pay 50% after deductible ($100 min/$200 max)/ You pay 50% after deductible ($215 min/$430 max) $0 if SaveOnSP eligible; You pay 30% after deductible ($200 min/$900 max)/ No 90-day supply of specialty medications $25 copay for 31-day supply; $75 for 61-90 day supply 15
What’s New and What’s Changing
This table shows you the changes between 2022-23 statewide premium price and this year’s 2023-24 regional price for your Education Service Center.
• Individual maximum-out-of-pocket decreased by $650.
Previous amount was $8,150 and is now $7,500.
• Family maximum-out-of-pocket decreased by $1,300. Previous amount was $16,300 and is now $15,000.
• Individual maximum-out-of-pocket increased by $450 to match IRS guidelines. Previous amount was $7,050 and is now $7,500.
• Family maximum-out-of-pocket increased by $900 to match IRS guidelines. Previous amount was $14,100 and is now $15,000. These changes apply only to in-network amounts.
• Family deductible decreased by $1,200. Previous amount was $3,600 and is now $2,400.
• Primary care provider copay decreased from $30 to $15.
• No changes.
• This plan is still closed to new enrollees.
Effective: Sept. 1, 2023
2022-23 Total Premium New 2023-24 Total Premium Change in Dollar Amount TRS-ActiveCare Primary Employee Only $417 $461 $44 Employee and Spouse $1,176 $1,245 $69 Employee and Children $751 $784 $33 Employee and Family $1,405 $1,568 $163 TRS-ActiveCare HD Employee Only $429 $475 $46 Employee and Spouse $1,209 $1,283 $74 Employee and Children $772 $808 $36 Employee and Family $1,445 $1,615 $170 TRS-ActiveCare Primary+ Employee Only $525 $541 $16 Employee and Spouse $1,284 $1,407 $123 Employee and Children $845 $920 $75 Employee and Family $1,614 $1,786 $172 TRS-ActiveCare 2 (closed to new enrollees) Employee Only $1,013 $1,013 $0 Employee and Spouse $2,402 $2,402 $0 Employee and Children $1,507 $1,507 $0 Employee and Family $2,841 $2,841 $0 Key Plan
At a Glance Primary HD Primary+ Premiums Lowest Lower Higher Deductible Mid-range High Low Copays Yes No Yes NetworkStatewide network Nationwide network Statewide network PCP Required? Yes No Yes HSA-eligible? No Yes No
Changes
16
www.trs.texas.gov Bene t TRS-ActiveCare Primary TRS-ActiveCare Primary+ TRS-ActiveCare HD TRS-ActiveCare 2 In-Network OnlyIn-Network OnlyIn-NetworkOut-of-NetworkIn-NetworkOut-of-Network Diagnostic Labs* Of ce/Indpendent Lab: You pay $0 Of ce/Indpendent Lab: You pay $0 You pay 30% after deductible You pay 50% after deductible Of ce/Indpendent Lab: You pay $0 You pay 40% after deductible Outpatient: You pay 30% after deductible Outpatient: You pay 20% after deductible Outpatient: You pay 20% after deductible High-Tech Radiology You pay 30% after deductible You pay 20% after deductible You pay 30% after deductible You pay 50% after deductible You pay 20% after deductible + $100 copay per procedure You pay 40% after deductible + $100 copay per procedure Outpatient Costs You pay 30% after deductible You pay 20% after deductible You pay 30% after deductible You pay 50% after deductible You pay 20% after deductible ($150 facility copay per incident) You pay 40% after deductible ($150 facility copay per incident) Inpatient Hospital Costs You pay 30% after deductible You pay 20% after deductible You pay 30% after deductible You pay 50% after deductible ($500 facility per day maximum) You pay 20% after deductible ($150 facility copay per day) You pay 40% after deductible ($500 facility per day maximum) Freestanding Emergency Room You pay $500 copay + 30% after deductible You pay $500 copay + 20% after deductible You pay $500 copay + 30% after deductible You pay $500 copay + 50% after deductible You pay $500 copay + 20% after deductible You pay $500 copay + 40% after deductible Bariatric Surgery Facility: You pay 30% after deductible Facility: You pay 20% after deductible Not CoveredNot Covered Facility: You pay 20% after deductible ($150 facility copay per day) Not Covered Professional Services: You pay $5,000 copay + 30% after deductible Professional Services: You pay $5,000 copay + 20% after deductible Professional Services: You pay $5,000 copay + 20% after deductible Only covered if rendered at a BDC+ facility Only covered if rendered at a BDC+ facility Only covered if rendered at a BDC+ facility Annual Vision Exam (one per plan year; performed by an ophthalmologist or optometrist) You pay $70 copayYou pay $70 copay You pay 30% after deductible You pay 50% after deductible You pay $70 copay You pay 40% after deductible Annual Hearing Exam (one per plan year) $30 PCP copay $70 specialist copay $30 PCP copay $70 specialist copay You pay 30% after deductible You pay 50% after deductible $30 PCP copay $70 specialist copay You pay 40% after deductible *Pre-certi cation for genetic and specialty testing may apply. Contact a PHG at 1-866-355-5999 with questions. Call a Personal Health Guide (PHG) any time 24/7 to help you nd the best price for a medical service. Reach them at 1-866-355-5999
Revised 05/30/23 17
Compare Prices for Common Medical Services
REMEMBER:
2023-24 Health Maintenance Organization (HMO) Plans and Premiums for Select Regions of the State
TRS contracts with HMOs in certain regions to bring participants in those areas additional options. HMOs set their own rates and premiums. They’re fully insured products who pay their own claims.
You can choose this plan if you live in one of these counties: Austin, Bastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Collin, Coryell, Dallas, Denton, Ellis, Erath, Falls, Freestone, Grimes, Hamilton, Hays, Hill, Hood, Houston, Johnson, Lampasas, Lee, Leon, Limestone, Madison, McLennan, Milam, Mills, Navarro, Robertson, Rockwall, Somervell, Tarrant, Travis, Walker, Waller, Washington, Williamson
You can choose this plan if you live in one of these counties: Cameron, Hildalgo, Starr, Willacy
You can choose this plan if you live in one of these counties: Andrews, Armstrong, Bailey, Borden, Brewster, Briscoe, Callahan, Carson, Castro, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Cottle, Crane, Crockett, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Fisher, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Haskell, Hemphill, Hockley, Howard, Hutchinson, Irion, Jones, Kent, Kimble, King, Knox, Lamb, Lipscomb, Llano, Loving, Lubbock, Lynn, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Runnels, San Saba, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Swisher, Taylor, Terry, Throckmorton, Tom Green, Upton, Ward, Wheeler, Winkler, Yoakum
Remember that when you choose an HMO, you’re choosing a regional network. REMEMBER: www.trs.texas.gov Total Monthly Premiums Total PremiumYour PremiumTotal PremiumYour PremiumTotal PremiumYour Premium Employee Only $596.96$ N/A$ N/A$ Employee and Spouse$1,501.90$ N/A$ N/A$ Employee and Children$960.68$ N/A$ N/A$ Employee and Family$1,728.86$ N/A$ N/A$ Central and North Texas Baylor Scott & White Health Plan Brought to you by TRS-ActiveCare Blue Essentials - South Texas HMO Brought to you by TRS-ActiveCare Blue Essentials - West Texas HMO Brought to you by TRS-ActiveCare
Prescription Drugs Drug Deductible $200 (excl. generics) N/A N/A Days Supply30-day supply/90-day supply N/A N/A Generics $14/$35 copay N/A N/A Preferred BrandYou pay 35% after deductible N/A N/A Non-preferred BrandYou pay 50% after deductible N/A N/A SpecialtyYou pay 35% after deductible N/A N/A Immediate Care Urgent Care $40 copay N/A N/A Emergency Care$500 copay after deductible N/A N/A Doctor Visits Primary Care $20 copay N/A N/A Specialist $70 copay N/A N/A Plan Features Type of CoverageIn-Network Coverage Only N/A N/A Individual/Family Deductible $2,400/$4,800 N/A N/A CoinsuranceYou pay 25% after deductible N/A N/A Individual/Family Maximum Out of Pocket $8,150/$16,300 N/A N/A
Revised 05/30/23 Only$553.45$
$14/$35 copay N/A N/A CoinsuranceYou pay 25% after deductible N/A N/A 18
Eastland, Ector, Fisher, Floyd, Gaines, Garza,
Health Savings Account (HSA)
EECU
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: Health Savings Account (HSA)
A Health Savings Account (HSA) is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. Health Savings Accounts enable you to save and conveniently pay for qualified healthcare expenses while you earn tax-free interest and pay no monthly service fees. An HSA is always yours even if you change health plans or jobs. 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.
HSA Eligibility
You are eligible to open and contribute to an HSA if you are:
• Enrolled in an HSA-eligible High Deductible Health Plan (HDHP)
• Not enrolled in Medicare, Medicaid, or TRICARE
• Not eligible to be claimed as a dependent on someone else’s tax return.
2023 Annual HSA Contributions Limits
• Individual: $3,850
• Family: $7,750
Catch Up Contribution: If you are 55 or older (regardless of when in the year you turn 55), you may make a yearly catch-up contribution of an additional $1,000.
Important HSA Information
• Annual election required.
• You can use your HSA for a wide range of qualified medical, dental or vision expenses for you and your eligible dependents, even if they are not covered under your medical plan.
• If you enroll in an HSA and FSA, then your FSA becomes a Limited Purpose FSA and may only be used for Dental and Vision, not medical expenses.
• Save your receipts for all qualified medical expenses.
You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit.
• 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.
• You may open an HSA at the financial institution of your choice, but only accounts opened through EECU are eligible for payroll deduction with Fort Worth ISD.
• Funds may be accessed via provided HSA Debit Card, Online Bill Pay, Online Transfers or Check.
• Online/Chat at www.eecu.org for 24/7 account access to check your balance, pay bills and more.
• Call Member Services at (817) 882-0800 for help with your HSA questions. Monday-Friday 8:00 a.m. to 7:00 p.m. CT, Saturday 9:00 a.m. – 1:00 p.m. CT.
• Lost/Stolen Debit Card: Call the 24/7 debit card hotline at (800) 333-9934
• Stop by a local EECU financial center for in-person assistance; find EECU locations & service hours at www. eecu.org/locations
EMPLOYEE
BENEFITS
19
Flexible Spending Account (FSA)
Higginbotham
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.
For full plan details, please visit your benefit website: Flexible Spending Account (FSA)
A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a preestablished amount of money per plan year in a Flexible Spending Account (FSA).
Funds allocated to the Flexible Spending Account (FSA)/ Limited Purpose FSA (LFSA)/Dependent Care FSA (DCFSA) must be used during the plan year or are forfeited. However, your plan contains an additional two month grace period to spend elected funds through October 31, 2024. Participants have until November 30, 2024 to submit out of pocket expenses incurred September 1, 2023 – October 31, 2024. Annual election required.
Flexible Spending Accounts & What They
Reimburse:
• Full Health Care FSA (FSA) – Medical, Dental, Vision expenses and over the counter items
• Limited Health Care FSA (LFSA) – Dental and Vision expenses ONLY
• Dependent Care FSA (DCFSA) – Day care, Before & Afterschool care, Day Camps & Elder Day Care
You do have the option to enroll in both a HSA and a FSA, however doing so will make your FSA a “Limited” FSA, which means it will only be available for dental and vision expenses. All medical expenses would need to be processed through your HSA.
How the Plans Work:
Health Care or Limited Purpose FSA funds may be accessed two different ways:
• Use your Higginbotham Benefits Debit Card to pay for qualified health expenses. Always keep receipts! Debit
cards will be suspended if you cannot substantiate the claim.
• Claims and receipts may be submitted for reimbursement.
Dependent Care FSA funds require claim submission, the Debit Card may not be utilized. Claims are not reimbursed until funds are available in the account and after services are rendered. Claims submitted prior to occurrence date will be denied and need to be resubmitted once incurred.
Submit claims and receipts to Higginbotham Flex Department by Fax (817) 882-9267, Email flexclaims@ higginbotham.net or Online at https://flexservices. higginbotham.net. For assistance call (866) 419-3519 or email flexsupport@higginbotham.net
Important FSA Information:
• The 2023 plan year maximum contribution to a Health Care FSA or Limited Purpose FSA is $3,050
• 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 an eligible Qualifying Life Event.
• Qualified Expenses Examples, Plan Details, Mobile App, Claim Forms and more are located on the Fort Worth ISD Benefit Website Home page. Look to the bottom left and select Flexible Spending Accounts.
• If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/ fortworthisd
EMPLOYEE BENEFITS
20
Dental Insurance
MetLife - Indemnity DPPO EMPLOYEE BENEFITS
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: Dental Indemnity PPO
MetLife Indemnity DPPO is replacing the United Concordia Indemnity DPPO plan effective 9/1/23. Employees currently enrolled in the United Concordia Plan will be rolled into the same tier of the MetLife Plan.
• Network: MetLife Preferred Dentist Program Plus Network
• Group Number and Carrier Information on page 3.
• ID Cards will be mailed for new enrollees. Access ID information via the MetLife app or from mybenefits.metlife.com
If a member received one exam and one cleaning in the prior year, the annual maximum for the member will increase by $250. If a member does not meet the criteria in a given year, their annual maximum would stay the same from the prior year’s amount. The increase will apply to a maximum of two step increases.
Plan Name In-Network Out-of-Network Individual Deductible $50 $50 Family Deductible $150 $150 Deductible Applies To Waive Type A Waive Type A Type A (Preventative/Diagnostic) Coinsurance 100% 100% Type B (Basic Restorative Care) Coinsurance 80% 80% Type C (Major Restorative Care) Coinsurance 50% 50% Annual Plan Maximum* (excludes Type A) $1,500 $1,500 Ortho Coinsurance 50% 50% Implants 50% 50% Ortho Lifetime Maximum (Adults and Children to age 26, benefit refreshes with $0 used towards lifetime maximum) $1,500 $1,500 R&C Percentile 90th Services Benefit Frequency Endodontics Non-Surgical (Basic or Major) Basic Prosthodontics 1 in 84 months Endodontics Surgical (Basic or Major) Basic Periodontal Maintenance 4 per year Periodontics Non-Surgical (Basic or Major) Preventive Bruxism Appliances 1 in 24 months Periodontics Surgical (Basic or Major) Basic Dental Implants 1 in 84 months Oral Surgery (Basic or Major) Basic
Plan
*Incentive
Indemnity DPPO Monthly Rates Employee Only $39.81 Employee + Spouse $80.12 Employee + Child(ren) $88.90 Family Coverage $129.03 21
Dental Insurance
Humana - Advantage Plus
Advantage Plus Monthly Rates
Employee Only $18.70
Employee + Spouse $38.26
Employee + Child(ren) $38.88
Family Coverage $63.90
• No Annual Maximum or deductibles
• Choose any participating dentist in Humana Dentals’ Advantage Plus network.
• Except for emergency care, treatment received out-ofnetwork is not covered.
• Group Number and Carrier Information on page 3.
• Office visit copay: $5/15
• View/Print ID information at Humana.com or via the MyHumana app.
Sample of Service Schedule
Review plan documents for complete schedule and plan details at https://www.mybenefitshub.com/fortworthisd/2023-2024/ Benefit/Humana/DPPO
Preventative Member Pays
Periodic oral examination no charge
Comprehensive oral evaluation (limit 1 every 24 months) no charge
X-ray/Bitewing no charge
Panoramic film (limit 1 every 3 years) no charge
Diagnostic casts no charge
Prophylaxis no charge
Topical application of fluoride—child (for child <16) no charge
Sealant—per tooth (limit 1 per tooth every 12 months for child <14) no charge
Basic Member Pays
Space maintainer— (limited to child <14)
Recementation of space maintainer
$53-$91
$12
Resin based composite $24-$56
Periodontal scaling and root planing— per quadrant, varies by number of teeth (limit 1 per quad every 12 months)
Full mouth debridement to enable comprehensive evaluation and diagnosis (limit 1 every 5 years)
Periodontal maintenance (limit 1 every 6 months, inclusive of D1110 and D1120)
Extraction coronal remnants deciduous tooth
Extraction erupted tooth or exposed root
Crown
Recement inlay, onlay or part coverage restoration
Recement crown
Sedative filling
Core buildup including any pins
Pin retention—per tooth addition restoration
Cast post and core in addition to crown
Prefabricated post and core in addition to crown
Therapeutic pulpotomy
Root canal therapy
Apicoectomy/periradicular surgery
Retrograde filling—per root
Gingivectomy/gingivoplasty
Gingival flap proc
Clinical crown lengthening—hard tissue
Osseous surgery—varies per number of teeth
Complete denture—maxillary or mandibular
Immediate denture—maxillary or mandibular
Maxillary or Mandibular partial denture
Adjust complete denture—maxillary
Surgical removal of residual tooth roots
Alveoloplasty —varies on in conjunction w/ extractions or not conjunction w/extraction and by number of teeth.
Incision and drainage of abscess— intraoral or extraoral
Frenulectomy—separate procedure.
Excision of hyperplastic tissue—per arch
Palliative treatment dental pain— minor procedure
$115 -$499
$41
$42
$44
$110
$23
$168
$139
$75
$315 -$601
$361 - $445
$109
$153-$358
$217-$421
$481
$354-$680
$642
$700
$542 --$709
$35
$114
$97 - 181
$120 - $570
$111
$272
$45
Local anesthesia no charge
IV conscious sedation/analg—1st 30 minute; each addition 15 minutes.
Professional consultation by non- treating dentist
$21- $39
$26
$23
$20
$26
Major Member Pays
Inlay
Onlay
$144; $60
$96
Orthodontics Member Pays
Comprehensive Orthodontic treatment. Up to 24 months of routine orthodontic treatment for class 1 and Class 2 cases.
Consultation no charge
Evaluation
Records/Treatment Planning
Orthodontic treatment (Children up to 19)
Orthodontic treatment (Adults 19 and up)
Retention
$313 -$414
$35
$250
$2100
$2300
$450
EMPLOYEE BENEFITS
Amalgam $24-$46
$403 - $461
22
Dental Insurance
Humana - DHMO
DHMO
• No annual maximums, no deductibles and no waiting periods.
• Scheduled costs for services provided by primary care dentist (PCD).
• Initial PCD assigned by residence zip codes, contact Humana to change PCD.
• Group Number and Carrier Information on page 3.
• View/Print ID information at Humana.com or via the MyHumana app.
Sample of Service Schedule
Review plan documents for complete schedule and plan details at https://www.mybenefitshub.com/fortworthisd/2023-2024/
Prosthodontics (Fixed)
Pontic; Crown $280
Recement fixed partial denture (per unit) $10
Endodontics
Therapeutic pulpotomy $35
Pulpal debridement, primary and permanent teeth $100
Root canal therapy
Each additional cast post—same tooth
Prefabricated post and core in addition to crown $90
$100-$250
Apicoectomy/periradicular surgery— anterior $125
Periodontics (Gum Treatment)
Gingivectomy/gingivoplasty per tooth/quadrant $40/$125
Periodontal scaling and root planing
$50
Full mouth debridement to enable comprehensive evaluation and diagnosis $45
Localized delivery of chemotherapeutic agents (per tooth)
Periodontal maintenance
Prosthodontics
Complete/Immediate/Partial Denture—maxillary or mandibular
Adjust denture
Repairs to Prosthetics
Repair broken complete denture base
Replace broken teeth—per tooth
Add tooth to existing partial denture
Reline denture (chairside)
Tissue conditioning
Extractions/Oral & Maxillofacial Surgery
$45
$50
$300+lab
$15
$15+lab
$15+lab
$30+lab
$ 50
$30
Member Pays
Extraction, erupted tooth or exposed tooth no charge
Surgical removal of erupted tooth
Removal of impacted tooth
Surgical removal of residual tooth roots
Alveoloplasty in conjunction with extractions
Incision and drainage of abscess
Anesthesia
$40
$50 - 85
$35
$35- 70
$25
Member Pays
Local anesthesia no charge
Analgesia (nitrous oxide), per 15 minutes
Adjunctive General Services
Palliative (emergency) treatment
Occlusal adjustment
Orthodontics
$15
Member Pays
$25
$ 25-$150
Member Pays
Comprehensive orthodontic treatment of the transitional/adolescent dentition; Up to 24 months of routine orthodontic treatment for Class I and Class II cases
Consultation no charge
Evaluation
Records/treatment planning
Orthodontic treatment (Children to 19)
Orthodontic treatment (Adult 19 and up)
Retention
$ 35
$ 250
$ 2,300
$ 2,500
$ 450
EMPLOYEE BENEFITS
Monthly Rates Employee Only $12.66 Employee + Spouse $22.60 Employee + Child(ren) $23.96 Family Coverage $31.18
Appointments Member Pays Office visit (normal hours) $5 Office visit (after hours) $35 Diagnostic Member Pays Periodic oral examination no charge Comprehensive periodontal evaluation $10 X-ray/Bitewings/Panoramic film no charge Pulp vitality tests no charge Diagnostic casts no charge Preventative Member Pays Prophylaxis (1 per 6 months) no charge Topical application of fluoride-child (up to 16 years of age) no charge Sealant-per tooth $ 10 Space maintainer-fixed/removable $ 45/$85 +lab Recementation of space maintainer $ 10.00 Restorative Member Pays Amalgam no charge Sedative filling $15 Resin based composite $35-$120 Inlay $95-$130 Crown and Bridge Member Pays Crown $280+lab Recement inlay or crown $15 Prefabricated stainless steel
$75 Core buildup, including
$45
Benefit/Humana/DHMO
crown— primary tooth
any pins
$15
$90+lab
Pin retention—per tooth, in addition to restoration
Cast post and core in addition to crown
$90lab
23
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: Vision Insurance
Vision Monthly Rates Benefit Frequency Employee Only $6.22 Exam Once every 12 months Employee + Spouse $12.45 Lenses or contact lenses Once every 12 months Employee + Child(ren) $11.84 Frames Once every 24 months Family Coverage $18.60 Group Number and carrier information on page 3. Vision Care Services with Humana In-Network Provider (Member Cost) Out-of-Network Reimbursement Exam with dilation as necessary Retinal imaging Contact lens exam • Standard Contact lens fit/follow up • Premium Contact lens fit/follow up $10 Up to $39 Up to $40 10% off retail $30 Not covered Not covered Not covered Lenses • Single Vision to Lenticular Sample Lens Options
UV coating
Tint • Standard Scratch resistance
Standard polycarbonate
Standard anti-reflective See plan for complete list of options $15 $15 $15 $15 $40 $45 Varies, see plan sheet Not Covered Not Covered Not Covered Not Covered Not Covered Frames $130 Allowance, 20 % off balance. $65 allowance Contacts (materials only) • Conventional • Disposable • Medically Necessary $130 allowance, 15% off balance. $130 allowance $0 $104 allowance $104 allowance $200 allowance Diabetic Eye Care and Testing $0, see plan sheet for details Varies, see plan sheet 24
Insurance Humana EMPLOYEE BENEFITS
•
•
•
•
Disability Insurance
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: Educator Disability
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. This coverage is provided by The Hartford.
CLAIMS: Call The Hartford Claims at (866) 547-9124 to file a claim, group number on page 3.
*If because of your disability you are hospital confined for 24 hours or more, the elimination period will be waived and benefits will be payable from the first day.
IMPORTANT NOTES
Elimination Period: You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Disability benefit payment. The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin. For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization.
Maximum Benefit Duration Benefit Duration is the maximum time for which the carrier will pay benefits for disability resulting from sickness or injury. Depending on plan option selected and age at which disability occurs, the maximum duration may vary. Age related adjustments may begin after age 60.
• Premium Option: plan max durations are the same for sickness or injury.
• Select Option: max benefits resulting from sickness is 5 years.
For details on Age Disabled variances see the applicable benefit schedules in plan documents at https://www.mybenefitshub. com/fortworthisd/2023-2024/Benefit/Hartford/EducatorLTD
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 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless you have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition, the carrier will pay benefits for a maximum of 4 weeks.
EMPLOYEE BENEFITS
Elimination Period (Days) Sample Premium for 30-34 year old Based on 12 payments per year Injury (Days) Sickness (Days) Premium Option (Accident and Sickness to 65) Monthly Benefit of $200 Selection Option (Accident to 65, Sickness 5 year) Monthly Benefit of $200 *14 *14 $6.72 $5.24 *30 *30 $5.78 $4.34 45 45 $4.82 $3.42 90 90 $4.18 $2.76
25
Cancer Insurance
American Public Life (APL)
ABOUT CANCER
Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.
For full plan details, please visit your benefit website: Cancer Insurance
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.
Claims: Claim form is on the Benefit Website, Group Number and Carrier Contact Information is on page 3.
EMPLOYEE BENEFITS
Summary of Benefits Plan 1 Plan 2 Cancer Treatment Policy Benefits 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 Cancer Screening Rider Benefits Diagnostic Testing - 1 test per calendar year $50 per test $50 per test Follow-Up Diagnostic Testing - 1 test per calendar year $100 per test $100 per test Medical Imaging - 1 test per calendar year $500 per test $500 per test Internal Cancer First Occurrence Rider Benefits Lump Sum Benefit - Maximum 1 per Covered Person per lifetime $5,000 $10,000 Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime $7,500 $15,000 Heart Attack/Stroke First Occurrence Rider Benefits Lump Sum Benefit - Maximum 1 per Covered Person per lifetime $5,000 $10,000 Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime $7,500 $15,000 Pre-Existing Condition Exclusion: No benefits are payable for any loss incurred during the first 12 months prior to the effective date of coverage and during the first 12 months of the effective date of coverage. Total Monthly Premiums by Plan Issue Ages Employee Employee & Spouse Employee & Child(ren) Employee & Family 18+ Plan 1 Plan 2 Plan 1 Plan 2 Plan 1 Plan 2 Plan 1 Plan 2 $15.66 $25.00 $33.38 $53.84 $18.30 $29.10 $36.02 $57.98 26
ABOUT LIFE AND AD&D
Group Optional 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:
Optional Term Life and AD&D
Life and Accidental Death and Dismemberment (AD&D) insurance through MetLife are important parts of your financial security, especially if others depend on you for support. With Life insurance, your beneficiary(ies) can use the coverage to pay off your debts, such as credit cards, mortgages and other final expenses.
Claims: Please contact the Fort Worth ISD Benefits office at 817814-2240 for assistance in filing a life claim.
Basic Life
$15,000 of Basic Life insurance is provided to eligible employees at Fort Worth ISD at no cost to you.
Optional Life and AD&D
You may purchase additional Life and AD&D insurance for you and your eligible dependents. If you decline Optional Life when first eligible and wish to elect later, Evidence of Insurability (EOI) – proof of good health – may be required before coverage is approved. You must be covered to obtain coverage for your dependents. Optional Life Plans may be ported. Porting and conversion options are available upon termination. Please see plan documents for details and limitations.
Employee Paid Optional Life Available
Coverage Employee
• Increments of $10,000 not to exceed $500,000.
• New Hire Guaranteed Issue $250,000 Spouse
• Increments of $10,000 up to 100% of employee amount, not to exceed $100,000
• New Hire Guaranteed Issue $50,000 Child(ren)
• Birth to age 26 - $5000, $10,000, or $15,000
Supplemental AD&D Coverage is equal to Optional Term Life amount.
Evidence of Insurability
If your coverage pends during open enrollment, you must complete and Statement of Health (SOH). Watch for an email from MetLife providing instructions or print the form at the end of the HUB walk-through. SOH must be completed within 30 days of enrollment or your election will be closed as incomplete. Questions on SOH should be directed to MetLife, contact information on page 3.
Designating a Beneficiary
A beneficiary is the person or entity you designate to receive the death benefits of your life policies. You can name more than one beneficiary and you can change beneficiaries at any time. If you name more than one beneficiary, you must identify the share for each.
*Covers all eligible children.
EMPLOYEE
BENEFITS
Optional Life and AD&D MetLife
Monthly Cost (Per $10,000) Age Employee Coverage Spouse Coverage 0-39 $0.76 $0.76 40-44 $2.35 $2.35 45-49 $2.35 $2.35 50-54 $3.11 $3.11 55-59 $6.25 $6.25 60-64 $8.79 $8.79 65+ $9.56 $9.56 Cost for your Child(ren)* $5,000 - $1.34 $10,000 - $2.67 $15,000 - $4.01
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Individual Life Insurance
ABOUT INDIVIDUAL LIFE
Individual insurance is a policy that covers a single person and is intended to meet the financial needs of the beneficiary, in the event of the insured’s death. This coverage is portable and can continue after you leave employment or retire.
For full plan details, please visit your benefit website: Individual Life Insurance
Voluntary permanent life insurance can be an ideal complement to the group term and optional term life insurance your employer might provide. This voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium.
To change beneficiaries or file a claim contact Texas Life, contact information is on page 3. You may apply for this permanent coverage, not only for yourself, but also for your spouse, children and grandchildren. You can qualify for coverage be answering just 3 questions, no exams or needles!
During the last six months, has the proposed insured:
1. Been actively at work on a full time basis, performing usual duties?
2. Been absent from work due to illness or medical treatment for a period of more than 5 consecutive working days?
3. Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation, dialysis treatment, or treatment for alcohol or drug abuse?
Offered by Texas Life Insurance, this plan features include:
• Long Guarantees. Guaranteed death benefit to age 121.
• High Death Benefit. With one of the highest death benefits available at the worksite. Give your loved ones peace of mind, knowing there will be life insurance in force when you die.
• Refund of Premium. If premium increase results in surrender of contract, plan offers a refund of 10 years’ premium.
• Accelerated Death Benefit Due to Terminal Illness Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months, you will have the option to receive 92% of the death benefit, minus a $150 administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive.
• Minimal Cash Value. Buy this policy for its life insurance protection, not its cash value. The primary benefit is life insurance.
Texas Life EMPLOYEE BENEFITS
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Accident Insurance
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: Accident Insurance
Chubb Accident pays cash benefits directly to you for covered accidents and Chubb Accident pays extra benefits for injuries resulting from participating in organized sports. Let Chubb Accident help take care of your bills so you can take care of yourself and your family.
Claims: Claim form is on the Benefit Website, Group Number and Carrier Contact Information is on page 3
Sample of Benefit Schedule--24-Hour Coverage
Review plan documents for complete schedule and plan details at https://www.mybenefitshub.com/fortworthisd/2023-2024/ Benefit/Chubb/Accident
Monthly Rates Gold Diamond Employee Only $9.40 $16.48 Employee + Spouse $17.16 $30.12 Employee + Child(ren) $19.32 $33.64 Family Coverage $27.08 $47.28
CHUBB EMPLOYEE BENEFITS Accident
Initial Care Gold Diamond Ambulance Ground Air $120 $1,000 $200 $2,000 Emergency Room $100 $200 Initial Doctor's Office Visit $50 $100 Urgent Care $50 $100 Hospital and Rehabilitation Gold Diamond Hospital Admission $500 $1,500 ICU Admission $1,000 $3,000 Rehabilitation Admission $500 $1,500 Hospital Confinement per day, up to 365 days $150 $250 ICU Confinement per day, up to 30 days $300 $500 Rehabilitation Confinement per day, up to 30 days $90 $150 Recovery per day, up to seven days $50 $100 Follow-up Care & Treatment Gold Diamond Concussion $60 $100 Follow-up Treatment per visit, up to 3 visits $25 $50 Major Diagnostic Exam (CT, MRI, etc.) $100 $200 Physical Therapy per visit, up to 10 visits $25 $50 X-ray $20 $40 Injuries Gold Diamond Coma $7,500 $12,500 Dislocations Open reduction, up to ... Closed reduction, up to ... $3,600 $1,800 $4,800 $2,400 Herniated Disc $400 $750 Knee Cartilage - Torn $400 $750 Lacerations $20-$300 $30-$500 Loss of Hands, Feet or Sight $10,000 $20,000 Loss of Fingers or Toes $1,200 $2,000 Additional Benefits Gold Diamond First Accident once per policy $100 $100 Sports Package Benefits are 25% higher when accident is due to participation in organized sports. Up to $1,000 per person per year. Accidental Death Employee & Spouse Child $20,000 $4,000 $50,000 $10,000 Catastrophic Accident Prior to Age 70 Employee & Spouse Child On or after Age 70 $20,000 $10,000 50% $50,000 $25,000 50% Family Care for each child in a child care center; per day, up to 30 days $25 $25 Wellness per person, once per year 90 days waiting period $50 $50 29
Legal Services
Texas Legal
ABOUT LEGAL SERVICES
Legal plans provide benefits that cover the most common legal needs you may encounter - like creating a standard will, living will, healthcare power of attorney or buying a home.
For full plan details, please visit your benefit website: Legal Services
Save Money and Protect your Family.
Legal insurance from Texas Legal lets you save money on legal services that everyone needs, such as estate planning, while protecting you from serious legal challenges that can come with life’s unknowns, including family, civil, consumer, and criminal issues.
Texas Legal is a non-profit founded by the State Legislature of Texas over 40 years ago. Our charter is simple - protect everyday Texans from financial hardship that can come with legal challenges. Available only to Texans, we offer the most comprehensive legal insurance plan on the market. As a member of Texas Legal, you can get high-quality legal help without the high price tag.
Legal Insurance Plans Cover:
• Estate Planning
• Divorce
• Bankruptcy
• Consumer Law
• Criminal Defense
• And Much More!
Two Plans are offered. Plan details and enrollment links are on the benefit website home page under Legal Services.
Questions/Claims:
Carrier Contact information is on Page 3.
BENEFITS
EMPLOYEE
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January Savings Plan
Fort Worth ISD
ABOUT JANUARY SAVINGS PLAN
The January Savings Plan provided by your employer is a way to set aside funds from your paycheck to offset unexpected holiday costs. During your open enrollment, you can choose a monthly amount to be deducted from your pay check on a regular basis through the scheduled date.
For full plan details, please visit your benefit website: www.mybenefitshub.com/fortworthisd
Voluntary enrollment in the January Savings Plan will only be allowed during Benefits Open Enrollment. No interest will be earned on the deduction amount. Deductions will be taken each payday as shown below:
The minimum monthly deduction is $10.00. If a semi-monthly employee selects $10.00 monthly, $5.00 will be taken each pay period marked in the table above. If a monthly employee selects $10.00 monthly, $10.00 will be taken each pay period marked in the table above. Disbursement of the total amount deducted through December will be direct deposited on January 12, 2024.
There will be NO early disbursements of funds
Funds in this account will NOT incur interest.
Monthly Dates
September 28, 2023
October 27, 2023
November 17, 2023
December 14, 2023
Semi-Monthly Dates
September 15, 2023
September 29, 2023
October 13, 2023
October 31, 2023
November 15, 2023
November 30, 2023
December 15, 2023
Questions on this plan should be directed to the payroll department, contact information on page 3.
EMPLOYEE
BENEFITS
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Emergency Medical Transport
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:
Emergency Medical Transport
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.
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 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 recuperation.
Claims
For claims assistance contact MASA, Carrier Contact information on page 3.
MASA EMPLOYEE BENEFITS
Features
Plus Membership Platinum Membership
Air Transportation x x Emergent Ground Transportation x x
InterFacility Transportation x x Repatriation/ Recuperation x x Escort Transportation x Visitor Transportation x Return Transportation x Mortal Remains Transportation x Minor Return x
Retrieval/Organ Recipient Transportation x Vehicle Return x Pet Return x Worldwide Coverage x Emergency Medical Transportation Emergent Plus Platinum Employee and Family $14.00 $39.00 32
Plan
Emergent
Emergency
Non-Emergency
Organ
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Notes
34
Notes
35
Notes
2023 - 2024 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 Fort Worth 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 Fort Worth 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/FORTWORTHISD
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