2023 - 2024 Plan Year
WTXEBC
BENEFIT GUIDE EFFECTIVE: 09/01/2023 - 8/31/2024 WWW.WTXEBC.COM
1
Table of Contents How to Enroll
4-5
Annual Benefit Enrollment
6-11
1. Section 125 Cafeteria Plan Guidelines
6
2. Annual Enrollment
7
3. Eligibility Requirements
8
4. Helpful Definitions
9
5. Health Savings Account (HSA) vs. Flexible Spending Account (FSA)
11-12
Hospital Cash
13-14
16-17
Vision
18-19
HOW TO ENROLL
PG. 6
SUMMARY PAGES
PG. 11
YOUR BENEFITS
20
Life and AD&D
21-22
Individual Life
23
Emergency Medical Transportation
24
Cancer
25-26
Accident
27-28
Critical Illness
29-30
Financial Wellness & ID Theft
PG. 4
15
Dental
Disability
2
10
Health Savings Account (HSA)
Telehealth
FLIP TO...
31
Flexible Spending Account (FSA)
32-33
FBS Benefits App Group # Index
34-35
Benefit Contact Information WTXEBC BENEFITS
HEALTH SAVINGS ACCOUNT (HSA)
HOSPITAL CASH
Financial Benefit Services (833) 453-1680 www.wtxebc.com TELEHEALTH
EECU (817) 882-0800 www.eecu.org
CHUBB Claims Assistance: (888) 499-0425 www.combinedinsurance.com VISION
MD Live (888) 365-1663 www.consultmdlive.com
DENTAL Lincoln Financial Group (800) 423-2765 https://www.lfg.com
DISABILITY
LIFE AND AD&D
Superior Vision Group #28790 (800) 507-3800 www.superiorvision.com INDIVIDUAL LIFE
Unum (866) 679-3054 www.unum.com EMERGENCY TRANSPORTATION
Unum (866) 679-3054 www.unum.com CANCER
5Star Life Insurance Company (866) 863-9753 www.5starlifeinsurance.com ACCIDENT
MASA (800) 423-3226 www.masamts.com
American Public Life (800) 256-8606 www.ampublic.com
CRITICAL ILLNESS
FINANCIAL WELLNESS & IDENTITY THEFT
The Hartford (800) 547-5000 www.thehartford.com FLEXIBLE SPENDING ACCOUNT (FSA)
CHUBB Claims Assistance: (888) 499-0425 www.combinedinsurance.com
Experian (866)-617-1894 www.experian.com
NBS (855) 399-3035 www.nbsbenefits.com
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All Your Benefits One App Employee benefits made easy through the FBS Benefits App! Text “FBS WTX” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment:
Text “FBS WTX” to (800) 583-6908
• Benefit Resources • Online Enrollment • Interactive Tools • And more!
App Group #:
Go to PAGE 34 to find your district’s group #
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OR SCAN
How to Log In 1
www.wtxebc.com
2
CLICK LOGIN
3
ENTER USERNAME & PASSWORD Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. If you have six (6) or less characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.
5
Annual Benefit Enrollment
SUMMARY PAGES
Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.
CHANGES IN STATUS (CIS):
QUALIFYING EVENTS
Marital Status
A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
Change in Number of Tax Dependents
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 Status of Employment Affecting Coverage Eligibility
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 of Dependents’ Eligibility Status
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
If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual’s plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.
Eligibility for Government Programs 6
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.
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
Annual Benefit Enrollment
SUMMARY PAGES
Annual Enrollment During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs. •
•
Changes, additions or drops may be made only during the annual enrollment period without a qualifying event. Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.
Where can I find forms? For benefit summaries and claim forms, go to your benefit website: www.wtxebc.com. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section. How can I find a Network Provider? For benefit summaries and claim forms, go to your benefit website: www.wtxebc.com. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.
When will I receive ID cards? If the insurance carrier provides ID cards, you can • Employees must confirm on each benefit screen expect to receive those 3-4 weeks after your effective (medical, dental, vision, etc.) that each dependent date. For most dental and vision plans, you can login to be covered is selected in order to be included in to the carrier website and print a temporary ID card the coverage for that particular benefit. 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 All new hire enrollment elections must be completed in the online enrollment system within the first 30 days carrier’s customer service number to request another card. of benefit eligibility employment. Failure to complete elections during this timeframe will result in the If the insurance carrier provides ID cards, but there are forfeiture of coverage. no changes to the plan, you typically will not receive a new ID card each year.
New Hire Enrollment
Q&A
Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefit Office or you can call Financial Benefit Services at 866-914-5202 for assistance.
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Annual Benefit Enrollment
SUMMARY PAGES
Employee Eligibility Requirements
Dependent Eligibility Requirements
Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.
Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.
Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2023 benefits become effective on September 1, 2023, you must be actively-at-work on September 1, 2023 to be eligible for your new benefits.
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PLAN
MAXIMUM AGE
Accident
Through 25
Cancer
Through 25
Critical Illness
Through 25
Dental
Through 25
Dependent Flex
12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes
Individual Life
Issue through 23; Keep to 121
Healthcare FSA
Through 25 or IRS Tax Dependent
Health Savings Account
IRS Tax Dependent
Identity Theft
Through 25
Medical Supplement
Through 25
Telehealth
Through 25
Vision
Through 25
Life and AD&D
Through 25
Medical Transportation
Through 25
Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents. Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility. FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse’s FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance. Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility. Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee’s enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts. If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your Benefit Office to request a continuation of coverage.
SUMMARY PAGES
Helpful Definitions Actively-at-Work
In-Network
You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2023 please notify your benefits administrator.
Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.
Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.
Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.
Calendar Year January 1st through December 31st
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).
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.
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SUMMARY PAGES
HSA 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, taxfree. 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 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)
Permissible Use Of Funds
Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.
Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).
Cash-Outs of Unused Amounts (if no medical expenses)
Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age Not permitted 65).
Year-to-year rollover of account balance?
Yes, will roll over to use for subsequent year’s health coverage.
No. Access to some funds may be extended if your employer’s plan contains a 2 1/2 –month grace period or $610 rollover provision.
Does the account earn interest?
Yes
No
Portable?
Yes, portable year-to-year and between jobs.
No
FLIP TO
FOR HSA INFORMATION
10
PG. 11
FLIP TO
FOR FSA INFORMATION
PG. 32
Health Savings Account (HSA) EECU
EMPLOYEE BENEFITS
ABOUT HSA A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used. Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP). For full plan details, please visit your benefit website: www.wtxebc.com
A Health Savings Account (HSA) is more than a way to help you and your family cover health care costs – it is also a taxexempt tool to supplement your retirement savings and cover health expenses during retirement. An HSA can provide the funds to help pay current health care expenses as well as future health care costs. A type of personal savings account, an HSA is always yours even if you change health plans or jobs. The money in your HSA (including interest and investment earnings) grows tax-free and spends tax-free if used to pay for qualified medical expenses. There is no “use it or lose it” rule — you do not lose your money if you do not spend it in the calendar year — and there are no vesting requirements or forfeiture provisions. The account automatically rolls over year after year.
HSA Eligibility You are eligible to open and contribute to an HSA if you are: • Enrolled in an HSA-eligible HDHP (High Deductible Health Plan) • Not covered by another plan that is not a qualified HDHP, such as your spouse’s health plan • Not enrolled in a Health Care Flexible Spending Account, nor should your spouse be contributing towards a Health Care Flexible Spending Account • Not eligible to be claimed as a dependent on someone else’s tax return • Not enrolled in Medicare or TRICARE • Not receiving Veterans Administration benefits 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.
Maximum Contributions Your HSA contributions may not exceed the annual maximum amount established by the Internal Revenue Service. The annual contribution maximum for 2023 is based on the coverage option you elect: • Individual – $3,850 • Family (filing jointly) – $7,750 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. 11
Health Savings Account (HSA) EECU
EMPLOYEE BENEFITS
Opening an HSA If you meet the eligibility requirements, you may open an HSA administered by EECU. You will receive a debit card to manage your HSA account reimbursements. Keep in mind, available funds are limited to the balance in your HSA.
Important HSA Information •
Always ask your health care provider to file claims with your medical provider so network discounts can be applied. You can pay the provider with your HSA debit card based on the balance due after discount. • You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit. 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.
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 through Friday from 8:00 a.m. to 7:00 p.m. CT, Saturday 9:00 a.m. – 1:00 p.m. CT and closed on Sunday.
•
Lost/Stolen Debit Card: Call 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 a www.eecu.org/ locations.
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Hospital Cash
EMPLOYEE BENEFITS
CHUBB
ABOUT HOSPITAL CASH 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.wtxebc.com
It’s not easy to pay hospital bills, especially if you have a high deductible medical plan. Chubb Hospital Cash pays money directly to you if you are hospitalized so you can focus on your recovery. And since the cash goes directly to you, there are no restrictions on how you use your money.
Hospital Cash Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Plan 2
$20.36 $40.68 $29.68 $50.00
$33.06 $73.39 $53.82 $81.19
Payable Benefit
Hospitalization and Rehabilitation Benefits
Plan 1
First Hospitalization Benefit This benefit is payable for the first covered hospital confinement per certificate. Hospital Admission Benefit This benefit is for admission to a hospital or hospital sub-acute intensive care unit. Hospital Admission ICU Benefit This benefit is for admission to a hospital intensive care unit.
• •
Hospital Confinement Benefit This benefit is for confinement in hospital or hospital sub-acute intensive care unit. Hospital Confinement ICU Benefit The benefit for confinement in a hospital intensive care unit.
• •
• • • •
• •
Newborn Nursery • This benefit is payable for an insured newborn baby receiving • newborn nursery care and who is not confined for treatment of a physical illness, infirmity, disease or injury. • Observation Unit This benefit is for treatment in a hospital observation unit for a period of less than 20 hours.
Plan 1
• •
$500 Maximum Benefit Per Certificate: 1 $1,500 Maximum Benefit Per Calendar Year: 3 $3,000 Maximum Benefit Per Calendar Year: 3 $100 Per Day Maximum Days Per Calendar Year: 30 $200 Per Day Maximum Days Per Calendar Year: 30 $500 Per Day Maximum Days per Confinement Normal Delivery: 2 Maximum Days per Confinement Caesarean Section: 2 $500 Maximum Days Per Calendar Year: 2
• • • • • • • • • • • • • • •
Plan 2 $1,000 Maximum Benefit Per Certificate: 1 $3,000 Maximum Benefit Per Calendar Year: 5 $6,000 Maximum Benefit Per Calendar Year: 5 $200 Per Day Maximum Days Per Calendar Year: 30 $400 Per Day Maximum Days Per Calendar Year: 30 $500 Per Day Maximum Days per Confinement Normal Delivery: 2 Maximum Days per Confinement Caesarean Section: 2 $500 Maximum Days Per Calendar Year: 2 13
Hospital Cash
EMPLOYEE BENEFITS
CHUBB
Payable Benefit Hospitalization and Rehabilitation Benefits (Continued) Plan 1 Rehabilitation Unit Admission Benefit This benefit is for admission to a rehabilitation unit as an inpatient. Rehabilitation Unit Confinement Benefit This benefit is for confinement in a rehabilitation unit.
• • • • •
Family Care Benefit • This benefit helps pay for childcare when an insured is confined in a hospital or rehabilitation unit. •
Medical Travel Benefit This benefit helps pay for travel expenses when an insured must travel at least 50 miles from their residence to receive special treatment or confinement in a hospital. Waiver of Premium Hospital Confinement This benefit waives premium when the employee is confined for more than 30 continuous days.
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• •
Plan 2
$500 Maximum Benefit Per Calendar Year: 3 $200 Per Day Payable per day for days 2 through 11 Maximum Days Per Calendar Year: 10 Childcare Benefit Per Day: $200 Maximum Days per Calendar Year: 10
• •
Per Day – 50 or more miles: $100 Maximum Days Per Calendar Year: 4
•
Included
• • • • •
•
$500 Maximum Benefit Per Calendar Year: 5 $400 Per Day Payable per day for days 2 through 11 Maximum Days Per Calendar Year: 10 Childcare Benefit Per Day: $200 Maximum Days per Calendar Year: 10 Per Day – 50 or more miles: $100 Maximum Days Per Calendar Year: 4 Included
Telehealth
EMPLOYEE BENEFITS
MDLive
ABOUT TELEHEALTH Telehealth provides 24/7/365 access to board-certified doctors via telephone or video consultations that can diagnose, recommend treatment and prescribe medication. Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available. For full plan details, please visit your benefit website: www.wtxebc.com 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
Registration is Easy
When to Use MDLIVE:
Telehealth Employee & Family
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.
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.
$9.00
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Dental Insurance
EMPLOYEE BENEFITS
Lincoln Financial Group ABOUT DENTAL
Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and disease. For full plan details, please visit your benefit website: www.wtxebc.com
The Lincoln DentalConnect® PPO Plans: • Cover many preventive, basic, and major dental care services • Also cover orthodontic treatment for children • Feature group rates for WTXEBC employees • Let you choose any dentist you wish, though you can lower your out-of-pocket costs by selecting a contracting dentist • Do not make you and your loved ones wait six months between routine cleanings
Dental MAC Plan Employee Only $20.10 Employee and Spouse $38.49 Employee and Child(ren) $48.83 Employee and Family $67.33
High Plan $34.87 $66.66 $84.88 $116.77
Benefit Highlights Some plans may not be offered at every district within WTXEBC. Check your district benefit website for details. MAC
Individual: $50 Family: $150 Waived for Preventive
Calendar (Annual) Deductible
High
Individual: $50 Family: $150 Waived for Preventive
Deductibles are combined for basic and major Contracting Dentists’ services. Deductibles are combined for basic and major Non-Contracting Dentists’ services. Annual Maximum
$1,500
$1,500
Lifetime Orthodontic Max
$1,000
$1,000
Orthodontic Coverage is available for dependent children. Waiting Period
There are no benefit waiting periods for any service types
Visit LincolnFinancial.com/FindADentist You can search by: • Location • Dentist name or office name • Distance you are willing to travel • Specialty, language and more Your search will automatically provide up to 100 dentists that most closely match your criteria. If your search does not locate the dentist you prefer, you can nominate one—just click the Nominate a Dentist llink and complete the online form. 16
Dental Insurance
EMPLOYEE BENEFITS
Lincoln Financial Group
Plan Features Some plans may not be offered at every district within WTXEBC. Check your district benefit website for details. Preventive Services
MAC
High
90% No Deductible
100% No Deductible
MAC
High
50% After Deductible
80% After Deductible
MAC
High
50% After Deductible
50% After Deductible
Orthodontics
MAC
High
Orthodontic exams X-rays Extractions Study models Appliances
50%
50%
Routine oral exams Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays - including periapical films Routine cleanings Fluoride treatments Space maintainers for children Palliative treatment - including emergency relief of dental pain Sealants Basic Services
Problem focused exams Injections of antibiotics and other therapeutic medications Fillings Simple extractions General anesthesia and I.V. sedation Major Services
Consultations Prefabricated stainless steel and resin crowns Surgical extractions Oral surgery Biopsy and examination of oral tissue - including brush biopsy Prosthetic repair and recementation services Endodontics - including root canal treatment
Contracting Dentists/Non-Contracting Dentists To find a contracting dentist near you, visit www.LincolnFinancial.com/FindADentist. This plan lets you choose any dentist you wish. However, your out-ofpocket costs are likely to be lower when you choose a contracting dentist. For example, if you need a crown…
Contracting Dentists
Non-Contracting Dentists
…you pay a deductible (if applicable), then 50% of the remaining discounted fee for PPO members. This is known as a PPO contracted fee.
… you pay a deductible (if applicable), then the remaining balance between the maximum allowable change and the dentist’s billed charge. You are responsible for the difference between the maximum allowable charge and the dentist’s billed charge.
MAC Option *Out of network reimbursement on this plan is based on the in-network fee schedule. This can mean more cost is incurred to you as the employee if you select this plan and see a dentist that is out of network. To find a in network dentist please visit to www.LincolnFinancial.com. 17
Vision Insurance
EMPLOYEE BENEFITS
Superior Vision ABOUT VISION
Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses. For full plan details, please visit your benefit website: www.wtxebc.com
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. Copays Exam Materials1 Contact lens fitting (standard & specialty)
$10 $25 $0
Exam (ophthalmologist) Exam (optometrist) Frames Contact lens fitting (standard2) Contact lens fitting (specialty2) Lenses (standard) per pair Single vision Bifocal Trifocal Scratch Coat (factory) Progressives lens upgrade Contact lenses4
Services/Frequency Exam 12 months Frame 12 months Contact lens fitting 12 months Lenses 12 months Contact lenses 12 months
Monthly Premiums Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
In-network Covered in full Covered in full $125 retail allowance Covered in full $50 retail allowance
Out-of-network Up to $42 retail Up to $37 retail Up to $68 retail Not covered Not covered
Covered in full Covered in full Covered in full Covered in full See description3 $120 retail allowance
Up to $32 retail Up to $46 retail Up to $61 retail Not covered Up to $61 retail Up to $100 retail
$7.80 $15.46 $15.17 $22.95
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1. Materials co-pay applies to lenses and frames only, not contact lenses 2. See your benefits materials for definitions of standard and specialty contact lens fittings 3. Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4. Contact lenses are in lieu of eyeglass lenses and frames benefit 18
Vision Insurance
EMPLOYEE BENEFITS
Superior Vision Discount Features
Look for providers in the provider directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary. Discounts on covered materials Frames:
20% off amount over allowance
Lens options:
20% off retail
Progressives:
20% off amount over retail lined trifocal lens, including lens options
Discounts on non-covered exam, services and materials Exams, frames, and prescription lenses:
30% off retail
Lens options, contacts, prescription materials options:
20% off retail
Disposable contact lenses:
10% off retail
Maximum member out-of-pocket Single Vision
Bifocal & Trifocals
Ultraviolet coat
$15
$15
Tints, solid or gradients
$25
$25
Anti-reflective coat
$50
$50
High index 1.6
$55
20% off retail
Photochromics
$80
20% off retail
The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) lenses.
5. Discounts and maximums may vary by lens type. Please check with your provider.
Refractive Surgery
Superior Vision has a nationwide network of independent refractive surgeons and partnerships with leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Benefit Office if you have any questions.
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Disability Insurance
EMPLOYEE BENEFITS
Unum
ABOUT DISABILITY Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time. For full plan details, please visit your benefit website: www.wtxebc.com
Who is eligible? You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. You are considered in active employment, if on the day you apply for coverage, you are being paid regularly by your employer for the required minimum hours each week and you are performing the material and substantial duties of your regular occupation. How can I apply for coverage? To apply for coverage, complete your enrollment online by the enrollment deadline. If you were hired after 9/1/2023, check with your plan administrator for your eligibility date, and complete your enrollment online within 31 days of that date. 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? You can elect to purchase a benefit of 30% 40% 50% 60% or 70% of your monthly earnings. What is my maximum monthly benefit amount? Your total monthly benefit (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost-of-Living Adjustment. How long do I have to wait to receive benefits? The elimination period is the length of time you must be continuously disabled before you can receive benefits. Elimination Period Options: • Option 1: 7 days/7 days first day hospital • Option 2: 14 days/14 days first day hospital • Option 3: 30 days/30 days first day hospital • Option 4: 60 days/60 days • Option 5: 90 days/90 days During your elimination period, you will be considered disabled if you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury, you are under the regular care of a physician and you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient 20
means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. Your admission and discharge dates and time must be 23 or more consecutive hours apart. (Applies to Elimination Periods of 30 days or less.) 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. 4 week pre-ex benefit included for pre-existing conditions. Please refer to policy for detailed description of this provision. When does my coverage end? Your coverage under the policy ends on the earliest of the following: • The date the policy or plan is cancelled • The date you no longer are in an eligible group • The date your eligible group is no longer covered • The last day of the period for which you made any required contributions • The last day you are in active employment except as provided under the covered layoff or leave of absence provision. Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.
Disability (per $100 in benefit) Elimination Period
30%
40%
50%
60%
70%
7/7
$1.68
$1.76
$2.03
$2.34
$2.84
14/14
$1.56
$1.65
$1.91
$2.20
$2.79
30/30
$1.30
$1.37
$1.59
$1.85
$2.24
60/60
$0.80
$0.84
$0.98
$1.21
$1.73
90/90
$0.71
$0.75
$0.88
$1.09
$1.53
Life and AD&D
EMPLOYEE BENEFITS
Unum
ABOUT LIFE AND AD&D Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered. For full plan details, please visit your benefit website: www.wtxebc.com
BASIC LIFE AND AD&D
Who is eligible? All actively employed employees working at least 15 hours each week for your employer in the U.S. and their eligible spouses and children to age 26. What are the Basic Life and AD&D coverage amounts? • Your employer is providing you with either $10,000, $20,000, $30,000, $40,000 or $50,000. Do my life insurance benefits decrease with age? Coverage amounts will reduce according to the following schedule: Age: Insurance amount reduces to: 65: 65% of original amount 70: 50% of original amount Coverage may not be increased after a reduction. When is coverage effective? Please see your plan administrator for your effective date. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. For your dependent spouse and children, insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Totally disabled means that as a result of an injury, sickness or disorder, your dependent spouse and children: are confined in a hospital or similar institution; are confined at home under the care of a physician for a sickness or injury; or your spouse has a life-threatening condition. Exception: Infants are insured from live birth. Is this coverage portable (can I keep it when I leave my employer)? If you retire, reduce your hours, or leave your employer, you can continue coverage for yourself your spouse and your dependent children at the group rate. Portability is not available for people who have a medical condition that could shorten their life
expectancy — but they may be able to convert their term life policy to an individual life insurance policy.
VOLUNTARY LIFE AND AD&D
Who is eligible? All actively employed employees working at least 20 hours each week for your employer in the U.S. and their eligible spouses and children to age 26. What are the Voluntary Life and AD&D coverage amounts? • Employee: up to 7 times salary in increments of $10,000; not to exceed $500,000. • Spouse: up to 100% of employee amount in increments of $10,000; not to exceed $500,000. • Child: up to 100% of employee coverage amount in increments of $5,000; not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and 14 days is $1,000 and 14 days to six months is $2,000. Do my life insurance benefits decrease with age? Coverage amounts will reduce according to the following schedule: Age: Insurance amount reduces to: 65: 65% of original amount 70: 50% of original amount Coverage may not be increased after a reduction. Can I be denied coverage? Current employees: If you and your eligible dependents are enrolled in the plan and wish to increase your life insurance coverage, you may apply on or before the enrollment deadline for any amount of additional coverage up to $200,000 for yourself and any amount of additional coverage up to $50,000 for your spouse. Any life insurance coverage over the guaranteed amount(s) will be subject to answers to health questions. If you and your eligible dependents are not currently enrolled in the plan, you may apply for coverage on or before the enrollment deadline and will be required to answer health questions for any amount of coverage. 21
Life and AD&D Unum
EMPLOYEE BENEFITS
New employees: To apply for coverage, complete your enrollment within 31 days of your eligibility period. If you apply for coverage after 31 days, or if you choose coverage over the amount you are guaranteed, you will need to complete a medical questionnaire which you can get from your plan administrator. You may also be required to take certain medical tests at Unum’s expense.
When is coverage effective? Please see your plan administrator for your effective date. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.
How much does coverage cost? Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date. Spouse rate is based on your Spouse’s insurance age, which is their age immediately prior to and including the anniversary/ effective date.
For your dependent spouse and children, insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Totally disabled means that as a result of an injury, sickness or disorder, your dependent spouse and children: are confined in a hospital or similar institution; are confined at home under the care of a physician for a sickness or injury; or your spouse has a life-threatening condition. Exception: Infants are insured from live birth.
Age band <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
Employee and Spouse Rate per $10,000 $0.54 $0.54 $0.72 $0.81 $0.99 $1.53 $2.88 $4.95 $7.92 $11.04 $18.54 $18.54 Child life monthly rate is $1.00 per $5,000.
What are the AD&D coverage amounts? • Employee: up to 10 times salary in increments of $10,000; not to exceed $500,000 • Spouse: up to 50% of employee amount in increments to a maximum of $250,000 • Child: up to 10% of employee coverage amount to a maximum of $50,000 Note: You may purchase AD&D coverage for yourself regardless of whether you purchase term life coverage. To purchase AD&D coverage for your dependents, you must buy coverage for yourself. What does AD&D insurance pay for? The full benefit amount is paid for loss of: • Life • both hands or both feet or sight of both eyes • one hand and one foot • one hand or one foot and the sight of one eye • speech and hearing Other losses may be covered as well. Please contact your plan administrator. How much does coverage cost? • Employee: $0.40 per $10,000 in coverage • Employee and Family: $0.70 per $10,000 in coverage 22
When does my coverage end? You and your dependents’ coverage under the Summary of Benefits ends on the earliest of: • the date the policy or plan is cancelled • the date you no longer are in an eligible group • the date your eligible group is no longer covered • the last day of the period for which you made any required contributions • the last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage. In addition, coverage for any one dependent will end on the earliest of: • the date your coverage under a plan ends • the date your dependent ceases to be an eligible dependent • for a spouse, the date of a divorce or annulment and • for dependent coverage, the date of your death Unum will provide coverage for a payable claim that occurs while you and your dependents are covered under the policy or plan. Is this coverage portable (can I keep it when I leave my employer)? If you retire, reduce your hours, or leave your employer, you can continue coverage for yourself your spouse and your dependent children at the group rate. Portability is not available for people who have a medical condition that could shorten their life expectancy — but they may be able to convert their term life policy to an individual life insurance policy. Will my premiums be waived if I become disabled? If you become disabled (as defined by your plan) and are no longer able to work, your life premium payments will be waived until your disability period ends.
Individual Life Insurance
EMPLOYEE BENEFITS
5Star
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: www.wtxebc.com
Enhanced coverage options for employees. Easy and flexible enrollment for employers. The 5Star Life Insurance Company’s Family Protection Plan offers both Individual and Group products with Terminal Illness coverage to age 121, making it easy to provide the right benefit for you and your employees CUSTOMIZABLE: With several options to choose from, employees select the coverage that best meets the needs of their families. TERMINAL ILLNESS ACCELERATION OF BENEFITS: Coverage that pays 30% (25% in CT and MI) of the coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months (24 months in IL). PORTABLE: Coverage continues with no loss of benefits or increase in cost if employment terminates after the first premium is paid. We simply bill the employee directly. CONVENIENCE: Easy payments through payroll deduction. FAMILY PROTECTION: Coverage is available for spouses and financially dependent children, even if the employee doesn’t elect coverage on themselves.
the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions. QUALITY OF LIFE: Optional benefit that accelerates a portion of the death benefit monthly, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or •
Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision.
ADDITIONAL DETAILS: Quality of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 14 days through 23 years). $7.15 monthly for $10,000 coverage per child. Find full details and rates at www.wtxebc.com Should you need to file a claim, contact 5Star directly at 866- 863-9753.
* Financially dependent children 14 days to 23 years old. PROTECTION TO COUNT ON: Within one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to
23
Emergency Transportation MASA
EMPLOYEE BENEFITS
ABOUT EMERGENCY TRANSPORTATION 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.wtxebc.com
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. Should you need assistance with a claim contact MASA at 800-643-9023. You can find full benefit details at www.wtxebc.com Emergency Transportation Employee & Family $14.00
24
Cancer Insurance
EMPLOYEE BENEFITS
APL
ABOUT CANCER Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment. For full plan details, please visit your benefit website: www.wtxebc.com
Treatment for cancer is often lengthy and expensive. While your health insurance helps pay the medical expenses for cancer treatment, it does not cover the cost of non-medical expenses, such as out-of-town treatments, special diets, daily living and household upkeep. In addition to these non-medical expenses, you are responsible for paying your health plan deductibles and/or coinsurance. Cancer insurance through American Public Life helps pay for these direct and indirect treatment costs so you can focus on your health. Summary of Benefits Cancer Treatment Policy Benefits Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12 month period Hormone Therapy - Maximum of 12 treatments per calendar year Experimental Treatment Surgical Rider Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime Miscellaneous Care Rider Benefits Cancer Treatment Center Evaluation or Consultation - 1 per lifetime Evaluation or Consultation Travel and Lodging - 1 per lifetime Second / Third Surgical Opinion - per diagnosis of cancer Drugs and Medicine - Inpatient / Outpatient (maximum $150 per month) Hair Piece (Wig) - 1 per lifetime Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane, or train Travel by car Lodging - up to a maximum of 100 days per calendar year Family Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Family Lodging - up to a maximum of 100 days per calendar year
Low Level 3
High Level 4
$15,000
$20,000
$50 per treatment paid in same manner and under the same maximums as any other benefit Level 1 Level 4 $30 unit dollar amount $60 unit dollar amount Max $3,000 per operation Max $6,000 per operation 25% of amount paid for covered surgery $6,000 $12,000 $600 $1,200 $1,000 / $100
$3,000 / $300
Level 4 Level 4 $750 $750 $350 $350 $300 / $300 $300 / $300 $150 per confinement / $50 per prescription $150 $150 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 25
Cancer Insurance
EMPLOYEE BENEFITS
APL
Miscellaneous Care Rider Benefits (cont’d) Blood, Plasma and Platelets Ambulance - Ground/Air - Maximum of 2 trips per Hospital Confinement for all modes of transportation combined Inpatient Special Nursing Services - per day of Hospital Confinement Outpatient Special Nursing Services - Up to same number of Hospital Confinement days Medical Equipment - Maximum of 1 benefit per calendar year Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year Waiver of Premium Internal Cancer First Occurrence Rider Benefits Lump Sum Benefit - Maximum 1 per Covered Person per lifetime Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime Heart Attack/Stroke First Occurrence Rider Benefits Lump Sum Benefit - Maximum 1 per Covered Person per lifetime Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime Hospital Intensive Care Unit Rider Benefits
Level 4 $300 per day
$200 / $2,000 per trip $150 per day $150 per day $150 $25 per visit / $1,000 Waive Premium Level 2 $5,000
Level 4 $10,000
$7,500
$15,000
Level 1
Intensive Care Unit Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit Should you need to file a claim contact APL at 800-256-8606 or online at www.ampublic.com. You can find additional claim forms and materials at www.wtxebc.com.
Cancer Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
26
Low $21.24 $38.10 $26.24 $39.94
High $34.30 $61.40 $42.30 $64.48
Level 4
Level 1 $2,500 $3,750 $600 per day $300 per day
Accident Insurance
EMPLOYEE BENEFITS
The Hartford
ABOUT ACCIDENT Do you have kids playing sports, are you a weekend warrior, or maybe accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you. For full plan details, please visit your benefit website: www.wtxebc.com
With Accident insurance, you’ll receive payment(s) Accident associated with a covered injury and related services. LOW HIGH You can use the payment in any way you choose – Employee Only $6.44 $13.42 from expenses not covered by your major medical Employee and Spouse $10.14 $21.16 plan to day-to-day costs of living such as the mortgage or your utility bills. You have a choice of two accident Employee and Child(ren) $10.73 $22.32 plans, which allows you the flexibility to enroll for the Employee and Family $16.92 $35.19 coverage that best meets your needs. This insurance provides benefits when injuries, medical treatment and/or services occur as the result of a covered accident. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s). BENEFITS EMERGENCY, HOSPITAL & TREATMENT CARE
LOW PLAN
HIGH PLAN
Accident Follow-Up
Up to 3 visits per accident
$150
$250
Accident Prevention Benefit
Once per year for each covered person
$50
$50
Chiropractic Care/PT
Up to 10 visits each per accident
Up to $50
Up to $100
Ambulance – Air
Once per accident
$2,500
$5,000
Ambulance – Ground
Once per accident
$2,500
$5,000
Blood/Plasma/Platelets
Once per accident
$200
$400
Daily Hospital Confinement
Up to 365 days per lifetime
$200
$600
Daily ICU Confinement
Up to 30 days per accident
$400
$800
Diagnostic Exam
Once per accident
$200
$400
Emergency Dental
Once per accident
Up to $300
Up to $600
Emergency Room
Once per accident
$150
$250
Hospital Admission
Once per accident
$1,000
$2,000
Initial Physician Office Visit
Once per accident
$150
$250
Lodging
Up to 30 nights per lifetime
$125
$175
Medical Appliance
Once per accident
$100
$300
Rehabilitation Facility
Up to 15 days per lifetime
$150
$450
Transportation
Up to 3 trips per accident
$400
$800
Urgent Care
Once per accident
$150
$250
X-ray
Once per accident
$100
$200
27
Accident Insurance
EMPLOYEE BENEFITS
The Hartford
BENEFITS (cont’d) SPECIFIED INJURY & SURGERY
LOW PLAN
HIGH PLAN
$2,000
$4,000
$250
$750
Abdominal/Thoracic Surgery
Once per accident
Arthroscopic Surgery
Once per accident
Burn
Once per accident
Burn – Skin Graft
Once per accident for third degree burn(s)
50% of burn benefit
Concussion
Up to 3 per year
$150
$250
Dislocation
Once per joint per lifetime
Up to $4,000
Up to $12,000
Eye Injury
Once per accident
Up to $500
Up to $1,000
Fracture
Once per bone per accident
Up to $8,000
Up to $12,000
Hernia Repair
Once per accident
$200
$600
Joint Replacement
Once per accident
$2,000
$6,000
Knee Cartilage
Once per accident
Up to $1,000
Up to $3,000
Laceration
Once per accident
Up to $500
Up to $1,500
Ruptured Disc
Once per accident
$1,000
$3,000
Tendon/Ligament/Rotator Cuff
Once per accident
Up to $1,500
Up to $3,000
LOW PLAN
HIGH PLAN
Up to $10,000 Up to $20,000
CATASTROPHIC Accidental Death
Within 90 days; Spouse @ 50% and child @ 25%
$50,000
$100,000
Common Carrier Death
Within 90 days
$75,000
$300,000
Coma
Once per accident
$10,000
$20,000
Dismemberment
Once per accident
Up to $50,000
Up to $100,000
Paralysis
Once per accident
Up to $50,000
Up to $100,000
Prosthesis
Once per accident
Up to $2,000
Up to $4,000
LOW PLAN
HIGH PLAN
FEATURES
25% increase of noncatastrophic benefits
Organized Amateur Sports Injury Enhancement Benefit Ability Assist® EAP2 – 24/7/365 access to help for financial, legal or emotional issues
Included
Included
HealthChampionSM3 – Administrative & clinical support following serious illness or injury
Included
Included
WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 20 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26. CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER? Yes. Any reference to “spouse” in this document includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law. 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. 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. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period or within 31 days of the date you have a change in family status. 28
WHEN DOES THIS INSURANCE BEGIN? 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). 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? This insurance will end when you or your dependents 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. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? 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. The specific terms and qualifying events for portability are described in the certificate.
Critical Illness Insurance CHUBB
EMPLOYEE BENEFITS
ABOUT CRITICAL ILLNESS Critical illness insurance can be used towards medical or other expenses. It provides a lump sum benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke. The money can also be used for non-medical costs related to the illness, including transportation, child care, etc. For full plan details, please visit your benefit website: www.wtxebc.com Heart attacks and strokes happen every day and often unexpectedly. They don’t give you time to prepare and can take a serious toll on both your physical and financial well-being. Chubb Critical Illness pays cash benefits directly to you that you can use to help with your bills, your mortgage, your rent, your childcare— you name it—so you can focus on recovery. No benefit will be paid for a date of diagnosis that occurs prior to the coverage effective date. Covered individuals must be treatment free from cancer for 12 months prior to diagnosis date and in complete remission. There is no pre-existing condition limitation. All amounts are Guaranteed Issue- no medical questions are required for coverage to be issued. Employee: $10,000; $20,000; $30,000; or $40,000 face amounts Spouse: $10,000; $20,000; $30,000; or $40,000 face amounts Child: Included in the employee rate Covered Conditions ALS Alzheimer's Disease Benign Brain Tumor Coma Coronary Artery Obstruction End Stage Renal Failure Heart Attack Loss of Sight, Speech, or Hearing Major Organ Failure Multiple Sclerosis Paralysis or Dismemberment Parkinson’s Disease Severe Burns Stroke Sudden Cardiac Arrest Transient Ischemic Attacks Miscellaneous Disease Rider + COVID-19 - The Miscellaneous Disease Rider is payable once per covered condition. Covered Conditions include: Addison’s Disease, Cerebrospinal Meningitis, Diphtheria, Huntington’s Chorea, Legionnaire’s Disease, Malaria, Myasthenia Gravis, Meningitis, Necrotizing Fasciitis, Osteomyelitis, Polio, Rabies, Scleroderma, Systemic Lupus, Tetanus, Tuberculosis. COVID-19 means a disease resulting in a positive COVID-19 diagnostic screening and 5 consecutive days of hospital confinement.
Payable Benefit as a % of Face Amount 100% 100% 100% 100% 25% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 10%
50%
29
Critical Illness Insurance
EMPLOYEE BENEFITS
CHUBB
Occupational Package - Pays 100% of the Face Amount; Benefits payable for HIV or Hepatitis B, C, or D, MRSA, Rabies, Tetanus, or Tuberculosis contracted on the job.
Included
Childhood Conditions - Pays 100% of the Dependent Child Face Amount; Provides benefits for childhood conditions (Autism Spectrum Disorder; Cerebral Palsy; Congenital Birth Defects; Heart, Lung, Cleft Lip, Palate, etc; Cystic Fibrosis; Down Syndrome; Gaucher Disease; Muscular Dystrophy; Type 1 Diabetes).
Included
Recurrence Benefit - Benefits are payable for a subsequent diagnosis of Aneurysm - Cerebral or Aortic, Benign Brain Tumor, Coma, Coronary Artery Obstruction, Heart Attack, Major Organ Failure, Severe Burns, Stroke, or Sudden Cardiac Arrest.
100%
Diabetes Diagnosis Benefit - Pays a benefit once for Covered Person’s Diabetes diagnosis.
$500
Wellness Benefit - Payable once per insured per year
$50
Critical Illness Age Band
18-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76+
Face Amount: Employee: $10,000; Spouse: $10,000; Child: $10,000 Employee Only
$0.74
$0.93
$0.96
$1.28
$1.65
$2.26
$2.84
$4.91
$7.65
$12.17
$15.42
$23.46
Employee and Spouse
$1.49
$1.86
$1.92
$2.56
$3.30
$4.51
$5.68
$9.82
$15.30 $24.34
$30.83
$46.91
Employee and Child(ren)
$0.74
$0.93
$0.96
$1.28
$1.65
$2.26
$2.84
$4.91
$7.65
$12.17
$15.42
$23.46
Employee and Family
$1.49
$1.86
$1.92
$2.56
$3.30
$4.51
$5.68
$9.82
$15.30 $24.34
$30.83
$46.91
Face Amount: Employee: $20,000; Spouse: $20,000; Child: $20,000 Employee Only
$1.49
$1.86
$1.92
$2.56
$3.30
$4.51
$5.68
$9.82
$15.30 $24.34
$30.83
$46.91
Employee and Spouse
$2.98
$3.71
$3.84
$5.12
$6.59
$9.02
$11.36 $19.65 $30.59 $48.67
$61.66
$93.82
Employee and Child(ren)
$1.49
$1.86
$1.92
$2.56
$3.30
$4.51
$5.68
$15.30 $24.34
$30.83
$46.91
Employee and Family
$2.98
$3.71
$3.84
$5.12
$6.59
$9.02
$11.36 $19.65 $30.59 $48.67
$61.66
$93.82
$46.25
$70.37
$9.82
Face Amount: Employee: $30,000; Spouse: $30,000; Child: $30,000 Employee Only
$2.23
$2.78
$2.88
$3.84
$4.94
$6.77
Employee and Spouse
$4.46
$5.57
$5.76
$7.68
$9.89
$13.54 $17.04 $29.47 $45.89 $73.01
$8.52
$92.50 $140.74
Employee and Child(ren)
$2.23
$2.78
$2.88
$3.84
$4.94
$6.77
$46.25
Employee and Family
$4.46
$5.57
$5.76
$7.68
$9.89
$13.54 $17.04 $29.47 $45.89 $73.01
$8.52
$14.74 $22.94 $36.50 $14.74 $22.94 $36.50
$70.37
$92.50 $140.74
Face Amount: Employee: $40,000; Spouse: $40,000; Child: $40,000 Employee
$2.98
$3.71
$3.84
$5.12
Employee and Spouse
$5.95
$7.42
$7.68
$10.24 $13.18 $18.05 $22.72 $39.30 $61.18 $97.34 $123.33 $187.65
Employee and Child(ren)
$2.98
$3.71
$3.84
$5.12
Employee and Family
$5.95
$7.42
$7.68
$10.24 $13.18 $18.05 $22.72 $39.30 $61.18 $97.34 $123.33 $187.65
30
$6.59 $6.59
$9.02 $9.02
$11.36 $19.65 $30.59 $48.67 $11.36 $19.65 $30.59 $48.67
$61.66 $61.66
$93.82 $93.82
Financial Wellness & ID Theft Experian
EMPLOYEE BENEFITS
ABOUT FINANCIAL WELLNESS & ID THEFT Experian Elite benefits plan features Digital Financial Managerproviding you tools to help manage your finances and credit profile in a single experience. 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.wtxebc.com
With features like Digital Financial Management, you will have tools to help manage your finances and credit profile in a single experience. 360° view of financial accounts Link your financial accounts to generate unique insights that can help improve your financial health and build good credit habits. Stay on top of your daily spending with recommended budgets powered by AI and machine learning of past transactional behavior. Exclusive credit insights Combine the power of financial transaction and credit data to unlock 50+ unique insights and recommendations to help achieve financial goals. Inisights are displayed in your personalized feed and categories include account activity, spending and budgeting, VantageScore®* improvements, financial updates, and more. Industry leading monitoring & alerts Consistent monitoring of your Experian® credit report and VantageScore* can help you better understand your current credit profile and personal finances. Financial Alerts will notify you, via push notifications and emails, when certain financial events are detected.
Elite Plan Monthly Premium Employee Only $7.50 Employee and Family $14.00
31
Flexible Spending Account (FSA) NBS
EMPLOYEE BENEFITS
ABOUT FSA A Flexible Spending Account allows you to pay for eligible healthcare expenses with a pre-loaded debit card. You choose the amount to set aside from your paycheck every plan year, based on your employer’s annual plan limit. This money is use it or lose it within the plan year (unless your plan contains a $610 rollover or grace period provision).). For full plan details, please visit your benefit website: www.wtxebc.com
Health Care FSA
The Health Care FSA covers qualified medical, dental and vision expenses for you or your eligible dependents. You may contribute up to $3,050 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include: • Dental and vision expenses • Medical deductibles and coinsurance • Prescription copays • Hearing aids and batteries You may not contribute to a Health Care FSA if you enrolled in a High Deductible Health Plan (HDHP) and contribute to a Health Savings Account (HSA).
How the Health Care FSAs Work
You can access the funds in your Health Care FSA two different ways: • Use your NBS Debit Card to pay for qualified expenses, doctor visits and prescription copays. • Pay out-of-pocket and submit your receipts for reimbursement: ∗ Fax – 844-438-1496 ∗ Email – service@nbsbenefits.com ∗ Online – my.nbsbenefits.com ∗ Call for Account Balance: 855-399-3035 ∗ Mail: PO Box 6980 West Jordan, UT 84084
Contact NBS • • • • •
Hours of Operation: 6:00 AM – 6:00 PM MST, Mon-Fri Phone: (800) 274-0503 Email: service@nbsbenefits.com Mail: PO Box 6980 West Jordan, UT 84084
Dependent Care FSA
The Dependent Care FSA helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full time. You can use the account to pay for day care or baby sitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you must be a single parent or you and your spouse must be employed outside the home, disabled or a full-time student. 32
Flexible Spending Account (FSA) NBS
EMPLOYEE BENEFITS
Dependent Care FSA Guidelines • • • •
Overnight camps are not eligible for reimbursement (only day camps can be considered). If your child turns 13 midyear, you may only request reimbursement for the part of the year when the child is under age 13. You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care. The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.
Important FSA Rules • • • • •
The maximum per plan year you can contribute to a Health Care FSA is $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 a Qualifying Life Event. You can continue to file claims incurred during the plan year for another 30 days (up until date). Your Health Care FSA debit card can be used for health care expenses only. It cannot be used to pay for dependent care expenses. The IRS has amended the “use it or lose it rule” to allow you to carry-over up to $610 in your Health Care FSA into the next plan year. The carry-over rule does not apply to your Dependent Care FSA.
Over-the-Counter Item Rule Reminder (OTC)
Health care reform legislation requires that certain over-the-counter (OTC) items require a prescription to qualify as an eligible Health Care FSA expense. You will only need to obtain a one-time prescription for the current plan year. You can continue to purchase your regular prescription medications with your FSA debit card. However, the FSA debit card may not be used as payment for an OTC item, even when accompanied by a prescription. Flexible Spending Accounts Account Type
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)
$3,050
Saves on eligible expenses not covered by insurance, reduces your taxable income
Dependent Care FSA
Dependent care expenses (such as day care, after-school programs or elder care programs) so you and your spouse can work or attend school full-time
$5,000 single $2,500 if married and filing separate tax returns
Reduces your taxable income
33
WTXEBC Mobile App Login Group #’s Use your District’s group # to login to the FBS Benefits app. District
GROUP #
District
GROUP #
Abernathy ISD
WTXA
Farwell ISD
WTXAK
Adrian ISD
WTXB
Floydada ISD
WTXAL
Amherst ISD
WTXC
Follett ISD
WTXAM
Anthony ISD
WTXD
Forsan ISD
WTXAO
Anton ISD
WTXE
Fort Elliott CISD
WTXAP
Archer City ISD
WTXF
Fort Stockton ISD
WTXAQ
Balmorhea ISD
WTXG
Friona ISD
WTXAR
Benjamin ISD
WTXI
WTXAS
Big Spring ISD
FBSBSISD
Garden City - Glasscock County ISD
Blackwell CISD
WTXJ
Grady ISD
WTXAT
Blanket ISD
WTXK
Grandfalls-Royalty ISD
WTXBD
Booker ISD
WTXL
Grandview - Hopkins ISD
WTXAU
Borger ISD
WTXM
Greenwood ISD
WTXBF
Bovina ISD
WTXN
Groom ISD
WTXAV
Brookesmith ISD
WTXP
Gruver ISD
WTXAW
Bryson ISD
WTXQ
Guthrie CSD
WTXAX
Canadian ISD
WTXR
Hale Center ISD
WTXAY
Channing ISD
WTXS
Happy ISD
WTXAZ
Cherokee ISD
WTXT
Harrold ISD
WTXAZZ4
Childress ISD
WTXU
Hart ISD
WTXHA
City View ISD
WTXV
Hartley ISD
WTXAAA
Clarendon CISD
WTXW
Hedley ISD
WTXABB
Coahoma ISD
WTXX
Henrietta ISD
WTXACC
Cotton Center ISD
WTXY
Hereford ISD
WTXBE
Crane ISD
WTXBA
Highland Park ISD
WTXADD
Crosbyton Consolidated ISD
WTXZ
Holliday ISD
WTXAEE
Crowell ISD
WTXAA
Idalou ISD
WTXAFF
Culberson County - Allamoore ISD
Iraan-Sheffield ISD
WTXAGG3
WTXAB
Jacksboro ISD
WTXAGG
Dalhart ISD
WTXAC
Jayton ISD
WTXAHH
Darrouzett ISD
WTXAD
Jim Ned CISD
WTXAII
Dimmitt ISD
WTXAE
Kelton ISD
WTXAJJ
Dumas ISD
WTXAF
Klondike ISD
WTXAKK
Eden CISD
WTXAG
Kress ISD
WTXALL
El Paso Education Initiative Inc
WTXAH
Lazbuddie ISD
WTXAMM
El Paso Leadership Academy
WTXAI
Lefors ISD
WTXANN
Electra ISD
WTXAJ
Lockney ISD
WTXAOO
34
WTXEBC Mobile App Login Group #’s Use your District’s group # to login to the FBS Benefits app. District
GROUP #
District
GROUP #
Loop ISD
WTXAPP
RISE Academy
WTXAYY1
Lorenzo ISD
WTXAQQ
River Road ISD
WTXAZZ1
May ISD
WTXARR
Robert Lee ISD
WTXAAA2
McLean ISD
WTXASS
Roosevelt ISD
WTXABB2
Meadow ISD
WTXATT
Ropes ISD
WTXACC2
Memphis ISD
WTXAUU
Saint Jo ISD
WTXADD2
Menard ISD
WTXAVV
Sands CISD
WTXAEE2
Miami ISD
WTXAWW
Sanford-Fritch ISD
WTXAFF2
Midland Academy Charter School
WTXAXX
Santa Anna ISD
WTXAGG2
Monahans-Wickett-Pyote ISD
WTXAYY
Seagraves ISD
WTXAHH2
Montague ISD
WTXAZZ
Shamrock ISD
WTXAII2
Morton ISD
WTXAAA1
Sierra Blanca ISD
WTXAJJ2
Munday CISD
WTXABB1
Smyer ISD
WTXAHH3
Nazareth ISD
WTXACC1
Southland ISD
WTXAKK2
New Home ISD
WTXADD1
Spring Creek ISD
WTXALL2
Newcastle ISD
WTXAEE1
Springlake-Earth ISD
WTXAFF3
Nocona ISD
WTXAFF1
Sudan ISD
WTXAMM2
Northside ISD
WTXAGG1
Sunray ISD
WTXANN2
O'Donnell ISD
WTXAHH1
Sweetwater ISD
WTXAOO2
Olfen ISD
WTXAII1
Texline ISD
WTXAQQ2
Olton ISD
WTXAJJ1
Throckmorton ISD
WTXARR2
Paducah ISD
WTXAKK1
Tulia ISD
WTXASS2
Paint Rock ISD
WTXALL1
Turkey-Quitaque ISD
WTXATT2
Panhandle ISD
WTXAMM1
Valentine ISD
WTXAUU2
Panther Creek CISD
WTXANN1
Vega ISD
WTXAVV2
Patton Springs ISD
WTXAOO1
Water Valley ISD
WTXAWW2
Petersburg ISD
WTXAPP1
Wellington ISD
WTXAXX2
Petrolia ISD
WTXAQQ1
Wheeler ISD
WTXAZZ2
Plains ISD
WTXARR1
White Deer ISD
WTXAAA3
Post ISD
WTXASS1
Whitharral ISD
WTXABB3
Prairie Valley ISD
WTXATT1
Wildorado ISD
WTXAZZ3
Pringle-Morse CISD
WTXAUU1
Wilson ISD
WTXACC3
Windthorst ISD
WTXADD3
Zephyr ISD
WTXAEE3
PSPartners
WTXBA
Quanah ISD
WTXAVV1
Ralls ISD
WTXAWW1
Rankin ISD
WTXAXX1 35
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 WTXEBC 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 WTXEBC 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.WTXEBC.COM 36