2014 CFBISD summary pages 07.01.14

Transcription

Carrollton-Farmers Branch
Independent School District
Employee Beneﬁt Guide
EFFECTIVE 09/01/2014 - 08/31/2015
/cfbisd
Table of Contents
1
Table of Contents, Contact Information
13
Cigna Dental DPPO
2
Online Benefits Enrollment
14
Cigna Dental DHMO
3
Annual Benefits Enrollment
15
Superior Vision
4-6
Employee Guide to Enroll in Benefits
16-18
Hartford Long-Term Disability
7
8
9-11
About this Benefits Summary
Helpful Definitions
TRS Medical
19-21
22
23
American Public Life Cancer
Lincoln Financial Accident Care
Dearborn Term Life/AD&D
12
American Public Life MEDLink
24-25
NBS Flexible Spending Accounts
Benefit Contact Information
Refer to this list when you need to contact one of your benefit providers. For general information please contact your
Benefits Department, Financial Benefit Services or log on to www.mybenefitshub.com/cfbisd
Program
Vendor
Phone Number
Website/Email
Carrollton Farmers Branch
ISD Benefits
Financial Benefit Services
(469) 385-4685
www.mybenefitshub.com/cfbisd
CFB Log In Help Desk
(972) 968-4357
helpdesk@cfbisd.edu
AETNA
(800) 222-9205
www.trsactivecareaetna.com
Caremark Pharmacy
(800)222-9205
www.caremark.com/trsactivecare
American Public Life (APL)
(800) 256-8606
www.ampublic.com
Dental
Cigna
(800) CIGNA24 (244-6224)
www.mycigna.com
Vision
Superior Vision
(800) 507-3800
www.superiorvision.com
The Hartford
(469) 385-4685
www.TheHartford.com
File a Disability Claim
(866) 278-2655
American Public Life (APL)
(800) 256-8606
www.ampublic.com
Lincoln Financial
(800) 423-2765
www.lfg.com
Dearborn National
(469) 385-4685
www.dearbornnational.com
National Benefit Services
(800) 274-0503
Automated balance line
(888) 353-9125
Medical—TRS Active Care
Medical Gap Plan
Disability
Cancer
Accident
Life and AD&D
Flexible Spending Accounts
Page 1
www.nbsbenefits.com
Online Benefits Enrollment
For benefit information and to enroll go to: www.mybenefitshub.com/cfbisd
1
Passwords
22
Please use your Carrollton Farmer’s Branch ISD username and
password to login.
Passwords
Passwords
3
For log in assistance, please contact the
C-FBISD Help Desk at helpdesk@cfbisd.edu or
972-968-4357
!
Enrollment Instructions
Click on “Enrollment Instructions” for more information about how to enroll .
Page 2
Benefits Questions? 469-385-4685
(call out, not a district extension)
Annual Benefits Enrollment
not
date is
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e
enrollm er 1, 2014 eff
b
m
te
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S
date.
C-FB ISD’s Enrollment is from
7/21/2014 through 8/25/2014
Benefit Updates - What’s New:
Benefit elections will become effective 9/1/2014 (elections
requiring evidence of insurability, such as Life Insurance, may
have a later effective date, if approved). After annual
enrollment closes, benefit changes can only be made within 30
days of a qualifying event.
Medical: Aetna will be the new health plan administrator and
CVS Caremark will be the new pharmacy manager.
- ActiveCare 1 HD & ActiveCare 2 plans are experiencing
a slight rate increase.
- TRS ActiveCare 3 will be eliminated! Enrollees in
TRS-AC 3 will be transitioned to TRS-AC 2 effective
9/1/14 unless you select another plan option during
the annual enrollment period
- New Plan: ActiveCare Select.
Cigna PPO Dental participants will experience a slight rate
increase effective 9/1/14.
NEW! C-FB ISD is adding a Cigna DHMO plan effective 9/1/14.
DHMO participants must designate a dentist.
QCD will be discontinued effective 9/1/14. Current QCD
participants without the Cigna PPO plan will roll to Cigna’s
DHMO plan & you must designate a dentist to receive benefits.
Don’t Forget!
If you currently have QCD but are also enrolled in Cigna’s PPO
plan, your QCD coverage will simply be removed.
If you currently participate in a Health Care or Dependent
Care FSA, you MUST re-elect a new contribution amount
every year to continue to participate.
If you currently have a NBS flex card, it is valid thru 8/31/14.
Current participants will receive new cards to the address
listed in THEbenefitsHUB. Funds will be available on the new
card by late September.
NEW! Vision carrier will now be Superior Vision.
NEW! Disability carrier will now be The Hartford.
NEW! Basic Life with AD&D & Voluntary Life with AD&D
carrier will now be Dearborn. Your Voluntary Life now has
AD&D benefits. Please contact the Benefit Dept. if you or a
covered dependent are not actively at work (able to work)
9/1/14 for further information on eligibility.
If you have current voluntary life coverage you are eligible to
increase your coverage $20,000 (not to exceed the
guaranteed issue amount) with no medical questions.
Login and complete your benefit enrollment from 7/21/2014-8/25/2014.
Enrollment assistance is available by calling Financial Benefit Services at (469) 385-4685 (This Is Not A District #!)
to speak to a representative (bilingual assistance is also available). M-F (8-5) Aug 18-Aug 29 hours extended to 7pm
Double check your profile information: (change home address, phone numbers, email thru the CFB Staff portal).
Update dependent social security numbers and student status for college-aged children.
Update your beneficiary designation.
C-FB ISD Employee Benefits HUB: www.mybenefitshub.com/cfbisd
Benefits Information access / Online Enrollment Access /
Page 3
FBS Contact Information
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 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 call Financial Benefit Services
at 469-385-4685 (Spanish representatives are available) for assistance.
You can also contact your Benefits Department at (972) 968-6130.
Where can I find forms?
For benefit summaries and claim forms, go to your school district’s benefit website: www.mybenefitshub.com/cfbisd No
need to Log In, just click on the benefit plan you need information about (i.e., Dental) on the Welcome Screen and you
can find the forms you need under the Benefits and Forms section.
How can I find a Network Provider?
Click on the benefit plan you need information about (i.e., Dental) and you can find provider search links under the Quick
Links section. For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/cfbisd
When will I receive ID cards?
If the insurance carrier provides ID cards, you can expect to receive ID cards 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. Your provider can call to 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.
This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included in
the summary plan description located on the C-FBISD Benefits Website: www.mybenefitshub.com/cfbisd
Page 4
Employee Eligibility Requirements
Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.
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 2014 benefits become effective on
September 1, 2014, you must be actively-at-work on
September 1, 2014 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, up to the maximum age listed below. Dependents cannot be double
covered by married spouses within the C-FBISD or as employees and dependents.
Plan
Carrier
Child Maximum Age
Continuation
Medical
Aetna
To 26
COBRA
Dental
Cigna
To 26
COBRA
Vision
Superior Vision
To 26
COBRA
Cancer
American Public Life
To 26
Portable
Within 30 days of termination
Accident
Lincoln Financial
Unmarried to 26
N/A
(may continue during leave)
Voluntary Life &
AD&D
Dearborn National
Medical Gap Plan
American Public Life
To 26
COBRA
Medical Flex
IRS Tax Dependent
COBRA
Dependent Flex
12 or younger or qualified individual
unable to care for themselves &
claimed as a dependent on your taxes
Not applicable
!
To 26 if a dependent for IRS at time of
Portable or Convertible
application for coverage of the child Within 30 days of termination
If your dependent is disabled, coverage can 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 for more
information .
This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included in the
summary plan description located on the C-FBISD Benefits Website: www.mybenefitshub.com/cfbisd
Page 5
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 (or approval date, if later) and will remain in
effect during the entire plan year.
Changes in pre-tax benefit elections can occur only if you
experience a qualifying event. You must present proof of a
qualifying event to your Benefit Office within 30 days of your
qualifying event and meet with your Benefit/Administrator
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
Marital Status
Qualifying Events
A change in marital status includes marriage, death of a spouse, divorce or annulment (legal
separation is not recognized in all states).
A change in number of dependents includes the following: birth, adoption and placement for
Change in Number of Tax
adoption. You can add existing dependents not previously enrolled whenever a dependent
Dependents
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.
An event that causes an employee's dependent to satisfy or cease to satisfy coverage
Gain/Loss of Dependents'
requirements under an employer's plan may include change in age, student, marital,
Eligibility Status
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
Judgment/Decree/Order 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
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
Programs
Page 6
!
About this Benefit Guide
This Benefit Summary provides highlights of your Carrollton
Farmer’s Branch Independent School District employee
benefits program. It is not a legal document and will not
guarantee benefits through Carrollton Farmer’s Branch ISD.
All benefit plans are governed by master policies, contracts
and
plan
documents.
Any
discrepancies
between
information provided through this summary and the actual
terms of the policies, contracts and plan documents are
governed by the terms of these policies, contracts and plan
documents.
Detailed
benefit
plan
documents
will
be
available on the Carrollton Farmer’s Branch ISD benefits
website
@
Page 7
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 9/1/2014 please notify your benefits
administrator.
Annual Enrollment
The period during which existing employees and their dependents are given the opportunity to enroll
in or change their current elections.
Annual Deductible
The amount you pay each plan year or calendar year (dependent on your plan design) before
the plan begins to pay covered expenses.
Calendar Year
January 1st through December 31st. Plan year definition below
Co-insurance
The percent of eligible charges that the plan pays and you pay after your deductible is met.
Sticky
i
notes
ation
exclam
points
may
contain
an
import
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 Enrollment and other times as approved and
is subject to limitations and exclusions.
In-Network
Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan.
Out-of-Pocket Maximum
The most an eligible or insured person can pay in coinsurance for covered
Expenses in their plan or calendar year (dependent on your plan design.)
Plan Year
September 1st through August 31st.
Pre-Existing Condition
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
within the designated period immediately preceding the effective date of change).
This is only a generic list of definitions, the definitions in the certificate of coverage or policy will govern.
Page 8
&
!
t info.
TRS ActiveCare C-FBISD Rates effective 9/1/14
ActiveCare 1HD
2014-2015 Monthly Premiums
2014-2015 Semi-Monthly Premiums
Coverage Tier
Employee Premium*
Employee Premium*
Employee Only
$63.00
$31.50
Employee & Spouse
$588.00
$294.00
Employee & Child(ren)
$310.00
$155.00
Employee & Family
$883.00
$441.50
Pooled Premium, both spouses in C-FBISD
$310.50
$155.25
Split Premium, spouse in different district**
$310.50
$155.25
* includes $262 district contribution
ActiveCare 1HD Plan Changes
Employee Only
Family
Deductible
$2,500
$5,000
Out-of-Pocket Max
$6,350
$9,200
ActiveCare Select - New Plan
2014-2015 Bi-Weekly Premiums
Coverage Tier
Employee Premium*
Employee Premium*
Employee Only
$188.00
$94.00
Employee & Spouse
$782.00
$391.00
$447.00
$223.50
Employee & Family
$976.00
$488.00
$357.00
$178.50
$357.00
$178.50
ActiveCare Select - New Plan
Individual
Family
Deductible
$1,200
$3,600
Out-of-Pocket Max
$6,350
$9,200
Baylor Accountable Care Organization Network in Dallas, no out of network coverage (except for emergencies)
Statewide EPO network outside of 4 urban areas
ActiveCare 2
2014-2015 Bi-Weekly Premiums
Coverage Tier
Employee Premium*
Employee Premium*
Employee Only
$293.00
$146.50
$1,025.00
$643.50
$613.00
$306.50
Employee & Spouse
Employee & Family
$1,061.00
$530.50
$399.50
$199.75
$399.50
$199.75
ActiveCare 2 Plan Changes
Individual
Family
Deductible
$1,000
$3,000
Out-of-Pocket Max
$6,000
$12,000
All enrollees in TRS-ActiveCare 3 will be transitioned to TRS-ActiveCare 2 effective 9/1/14 unless the employee selects another TRS-ActiveCare plan option during the annual
enrollment period for the 2014-2015 plan year.
ActiveCare 3 - Discontinued
All enrollees in TRS-ActiveCare 3 will be transitioned to TRS-ActiveCare 2 effective 9/1/14 unless the employee selects another TRS-ActiveCare plan option during the annual
enrollment period for the 2014-2015 plan year.
**Contact C-FBISD for required TRS Split Agreement form
rev 6.24.2014
Page 9
2014–2015 TRS-ActiveCare Plan Highlights
Effective September 1, 2014 through August 31, 2015 | Network Level of Benefits*
ActiveCare 1-HD
Type of Service
ActiveCare Select
ActiveCare 2
Deductible
(per plan year)
$2,500 employee only
$5,000 employee and spouse; employee
and child(ren); employee and family
$1,200 individual
$3,600 family
$1,000 individual
$3,000 family
Out-of-Pocket Maximum
(per plan year; does include medical
deductible/any medical copays/
coinsurance)
$6,350 employee only**
$9,200 employee and spouse; employee
and child(ren); employee and family**
$6,350 individual
$9,200 family
$6,000 per individual
$12,000 family
80%
20%
80%
20%
80%
20%
Office Visit Copay
Participant pays
20% after deductible
$30 copay for primary
$60 copay for specialist
Diagnostic Lab
Plan pays 100% (deductible waived) if
performed at a Quest facility; 20% after
deductible at other facility
Plan pays 100% (deductible waived) if
performed at a Quest facility; 20% after
deductible at other facility
Preventive Care
See reverse side for a list of services
Plan pays 100%
Plan pays 100%
Plan pays 100%
Teladoc Physician Services
$40 consultation fee (applies to deductible
and out-of-pocket maximum)
Plan pays 100%
Plan pays 100%
High-Tech Radiology
(CT scan, MRI, nuclear medicine)
Participant pays
$100 copay plus 20% after deductible
Inpatient Hospital
(preauthorization required)
(facility charges)
Participant pays
$150 copay per day plus 20% after deductible
($750 maximum copay per admission)
$150 copay per day plus 20% after deductible
($750 maximum copay per admission;
$2,250 maximum copay per plan year)
Emergency Room
(true emergency use)
Participant pays
(copay waived if admitted)
(copay waived if admitted)
Outpatient Surgery
Participant pays
$150 copay per visit plus 20% after deductible
$150 copay per visit plus 20% after deductible
Bariatric Surgery
Physician charges (only covered if
performed at an IOQ facility)
Participant pays
$5,000 copay plus 20% after deductible
Not covered
$5,000 copay (does not apply to out-of-pocket
maximum) plus 20% after deductible
Prescription Drugs
Drug deductible (per plan year)
Subject to plan year deductible
$0 for generic drugs
$200 per person for brand-name drugs
$0 for generic drugs
$200 per person for brand-name drugs
Retail Short-Term
(up to a 31-day supply)
• Generic copay
• Brand copay (preferred list)
• Brand copay (non-preferred list)
Participant pays
$20
$40***
50% coinsurance
$20
$40***
$65***
Retail Maintenance
(after first fill; up to a 31-day supply)
• Generic copay
Participant pays
$25
$50***
50% coinsurance
$25
$50***
$80***
Mail Order and Retail-Plus
(up to a 90-day supply)
• Generic copay
Participant pays
$45
$105***
50% coinsurance
$45
$105***
$180***
Specialty Drugs
Participant pays
20% coinsurance per fill
$200 per fill (up to 31-day supply)
$450 per fill (32- to 90-day supply)
Coinsurance
Plan pays (up to allowable amount)
Participant pays (after deductible)
A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when network providers are used. For some plans non-network benefits are also available; see
Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which may
be considerable. **Includes prescription drug coinsurance ***If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost
difference between the brand-name drug and the generic drug.
Page 10
2014–2015 TRS-ActiveCare Plan Highlights
TRS-ActiveCare Plans – Preventive Care
Network Benefits
When Using Network Providers
(Provider must bill services as “preventive care”)
Preventive Care Services
Evidence−based items or services that have in effect a rating of
“A” or “B” in the current recommendations of the United States
Preventive Services Task Force (USPSTF)
Immunizations recommended by the Advisory Committee on
Immunization Practices of the Centers for Disease Control and
Prevention (CDC) with respect to the individual involved
Evidence−informed preventive care and screenings provided for in
the comprehensive guidelines supported by the Health Resources
and Services Administration (HRSA) for infants, children and
adolescents. Additional preventive care and screenings for women,
not described above, as provided for in comprehensive guidelines
supported by the HRSA.
For purposes of this benefit, the current recommendations of the
USPSTF regarding breast cancer screening and mammography
and prevention will be considered the most current (other than
those issued in or around November 2009).
The preventive care services described above may change as
USPSTF, CDC and HRSA guidelines are modified.
Examples of covered services included are routine annual
physicals (one per year); immunizations; well-child care;
breastfeeding support, services and supplies; cancer screening
mammograms; bone density test; screening for prostate cancer
and colorectal cancer (including routine colonoscopies); smoking
cessation counseling services and healthy diet counseling; and
obesity screening/counseling.
Examples of covered services for women with reproductive
capacity are female sterilization procedures and specified
FDA-approved contraception methods with a written prescription
by a health care practitioner, including cervical caps, diaphragms,
implantable contraceptives, intra-uterine devices, injectables,
transdermal contraceptives and vaginal contraceptive devices.
Prescription contraceptives for women are covered under the
pharmacy benefits administered by Caremark. To determine
if a specific contraceptive drug or device is included in this
benefit, contact Customer Service at 1-800-222-9205. The list
may change as FDA guidelines are modified.
ActiveCare 1-HD
ActiveCare Select
ActiveCare 2 Network
Plan pays 100% (deductible waived)
Plan pays 100% (deductible waived;
no copay required)
Plan pays 100% (deductible waived;
no copay required)
Annual Vision Examination
(one per plan year)
After deductible, plan pays 80%;
participant pays 20%
Annual Hearing Examination
After deductible, plan pays 80%;
participant pays 20%
Note: Covered services under this benefit must be billed by the provider
as “preventive care.” If you receive preventive services from a non-network
provider, you will be responsible for any applicable deductible and
coinsurance under the ActiveCare 1-HD and ActiveCare 2. There is no
coverage for non-network services under the ActiveCare Select plan.
TRS-ActiveCare 3 to be discontinued effective September 1, 2014
The Teacher Retirement System of Texas (TRS) regularly reviews the
TRS-ActiveCare plan options to ensure the plans meet the health care
needs of public school employees and their families. Based on this
review, TRS will eliminate the ActiveCare 3 option for the 2014-2015
plan year.
TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits
are administered by Caremark.
Page 11
APL MEDlink® IV Gap - Group #13633 Carrollton-Farmers Branch ISD
MEDlink® IV Supplemental Limited Benefit Medical Expense Insurance is designed to help supplement your employer’s major medical insurance plan
and can help cover some of your out-of-pocket expenses. The available plan options based on enrollment in TRS ActiveCare 1HD, ActiveCare 2 or
ActiveCare Select medical plans. You are not eligible for MEDlink® IV if any of the following apply: You (or your dependents) are not covered under
the school’s major medical plan, covered by TRS-Care (retiree plan), Medicare, Medicaid, have a Medical Savings Accounts (an actively-funded
HSA) or are non-residents of the United States, Employees not actively at work on the plan effective date are not eligible.
Base Policy
Maximum In-Hospital Benefits
In-Hospital Ambulance Benefit
Enhanced Plan Summary of Benefits*
Option 1
$1,500 per Covered Person per Confinement.
$2,500 per Covered Person per Confinement.
Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person
is Confined as an Inpatient. Limited to one trip per day.
In-Hospital Deductible
Pre-Existing Period
Option 2
$0 per Covered Person per Confinement
The Pre-Existing Period is 12 months prior to the effective date of coverage. This product has a Pre-Existing
Condition Limitation. The Pre-Existing Condition Limitation will apply only if the Covered Person is subject to a
Pre-Existing Condition Limitation under the Other Medical Plan. Therefore, any Pre-Existing Condition Limitation
applied to the Major Medical plan would, in effect, limit coverage under this plan.
Outpatient Benefit Rider
Maximum Outpatient Benefits
Outpatient Ambulance Benefit
$500 per Covered Person per Occurrence for Covered Outpatient Services
Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a
Covered Person resides less than 18 hours. Limited to one trip per day.
Outpatient Deductible
$0 per Covered Person Per Occurrence
Covered Outpatient Services
Hospital Emergency Room
Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.
Urgent Care Facility
Maximum of three Urgent Care visits per Covered Person per Calendar Year. Maximum of six Urgent Care visits per
Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the
Outpatient Benefit Deductible, as shown above.
Outpatient Surgery
Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the
Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.
Diagnostic Testing
Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit,
subject to the Outpatient Benefit Deductible, as shown above.
Outpatient Treatment for a
Serious Mental Illness in a
Hospital Outpatient Facility
Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum
Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.
Benefit Rider
Physician Outpatient
Treatment Benefit Rider
$25 per visit; Maximum of four visits per Covered Person per Calendar Year and eight visits per Calendar Year
for all Covered Persons combined for treatment in a Hospital Outpatient Facility, Freestanding Emergency Care
Clinic, Urgent Care Facility/Clinic, or Physician Office
Total Monthly Premiums by Plan**
Age 18 +
Option 1
Option 2
Employee
$33.50
$40.32
Employee & Spouse
$77.48
$93.14
Employee & Child
$60.48
$72.06
Employee & Family
$104.36
$124.80
*The premium and amount of benefits vary dependent upon the option selected.
**Total premium includes the policy and riders of the option selected.
Must be used in conjunction with brochure APSB-22132 series. To view click here
This product is inappropriate for people who are eligible for Medicaid coverage.
This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included in the summary
plan description located on the Carrollton-Farmers Branch ISD Benefits Website: www.mybenefitshub.com/cfbisd
APESB-449
Page 12
Underwritten by American Public Life Insurance Company
Cigna PPO Dental - Group #3334580
All deductibles, plan maximums & service specific maximums (dollar & occurrence) cross accumulate between in & out of
network on the Cigna DPPO Choice. Ask if your dentist is contracted in the RADIUS network.
Benefits
Class I - Preventative & Diagnostic Care
Oral Exams
Routine Cleanings
Bitewing, Full Mouth & Panoramic X-Rays
Fluoride Application
Sealants
Space Maintainers
Histopathologic Exams
Class II Basic Restorative Care
Filings
Emergency Care to Relieve Pain
Root Canal Therapy/Endodontics
Osseous Surgery
Periodontal Scaling and Root Planning
Surgical Extractions of Impacted Teeth
Brush Biopsies
Oral Surgery -all except simple extractions
Anesthetics
Oral Surgery - Simple Extractions
Class III Major Restorative Care
Crowns
Denture Repairs
Denture Relines, Rebases and Adjustments
Repairs to Bridges, Crowns & Inlays
Dentures
Bridges
Inlays/Onlays
Prosthesis Over Implant
Class IV Orthodontia
Lifetime Max.
$1,000 Dependent children to age 19
In-Network & Out-of-Network
Plan Pays
You Pay
80%
20%
Plan Pays
You Pay
Benefits
Network
In-Network
Choice-Radius
Out-of-Network
Savings-Radius
Plan Year Max
$1,500
$1,500
Annual Deductible
Individual
$50 per person
$50 per person
Family
$150 per family $150 per family
90th percentile of
Reimbursement Based on Reduced Reasonable &
Levels**
Contracted Fees Customary
Allowances.
now?
Did You K
60%
40%
Cigna now has a
myCigna Mobile App.
Download it on your
Smart Phone today!
Plan Pays
You Pay
Monthly PPO Premiums
60%
40%
Plan Pays
You Pay
50%*
50%*
Tier
Rate
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
$36.55
$80.71
$73.12
$121.49
!
Cigna DPPO Dental Network Savings Plan
(DNSP):
Using an out-of-network dental health care
provider will cost you more than using
in-network care. Pre-Treatment review is
available on a voluntary basis when
extensive dental work in excess of
$200 is proposed.
the summary plan description located on the Carrollton-Farmers Branch ISD Benefits Website: www.mybenefitshub.com/cfbisd
Page 13
Cigna DHMO - Group #3334580
If you were enrolled in the QCD Dental & Vision plan you will automatically be rolled to the DHMO plan. With the Cigna Dental
DHMO plan there are no plan maximums, deductibles or claim forms to file. You must designate a dentist and provide the
facility code when you enroll. Specialty dentists require a referral from your network dentist.
!
For a Complete Fee Schedule please visit:
Service Code
DHMO with Ortho
Service Description
Patient Charge
D1110
Prophylaxis (cleaning) – Adult (limit 2 per calendar year)
No charge
D0120
Periodic Oral Evaluation - Established Patient
No charge
D0150
Comprehensive oral evaluation – New or established patient
No charge
D0210
X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years)
No charge
D0274
X-rays (bitewings) – 4 radiographic images
No charge
D0330
X-rays (panoramic radiographic image) – (limit 1 every 3 years)
No charge
D1351
D1510
D2161
D6740
D6930
D3330
D5110
D9220
Sealant – Per tooth
Space maintainer – Fixed – bilateral
Amalgam – 4 or more surfaces, primary or permanent
Crown – Porcelain/ceramic
Recement fixed partial denture
Molar root canal – Permanent tooth (excluding final restoration)
Full upper denture
General anesthesia – First 30 minutes
$17.00
$170.00
$40.00
$530.00
$65.00
$595.00
$450.00
$190.00
D7140
Extraction, erupted tooth or exposed root - elevation and/or forceps removal
$64.00
D8670
Periodic orthodontic treatment visit – As part of contract
Children Up to 19th birthday
24-month treatment fee
Charge per month for 24 months
D8670
Periodic orthodontic treatment visit – As part of contract
Adults 24-month treatment fee
Charge per month for 24 months
$2,472.00
$103.00
$3,384.00
$141.00
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Employee + Spouse
Employee + Family
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$8.98
$19.04
$19.04
$26.04
Page 14
Superior Vision
Members pay a co-pay for in-network benefits. Out-of-network vision services are reimbursed up to a certain dollar amount
for covered expenses. The in-network exam co-pay is $10.00 and the materials co-pay is $25.00. Exams and lenses (within
plan allowance) and frames are covered in-network with a co-pay, once every 12 months.
Vision Plan Benefits
Benefits
In-Network
Out-of-Network
Exam (ophthalmologist)
Covered in full
Up to $42 retail
Exam
$10
Exam (optometrist)
Covered in full
Up to $37 retail
$25
Frames
$140 retail allowance
Up to $53 retail
Contact Lens fitting (standard₂)
Covered in full
Not Covered
Materials₁
Contact Lens Fitting
(standard & specialty)
Contact Lens fitting (specialty₂)
Not Covered
Contact Lenses
Up to $100 retail
Single Vision
Covered in full
Up to $26 retail
Bifocal
Covered in full
Up to $34 retail
Trifocal
Covered in full
Up to $50 retail
Polycarbonate for dependent children
Covered in full
Not Covered
Photochromic, Tints, Solid or Gradients
Covered in full
Not Covered
Progressive lens upgrade
See description₃
Up to $50 retail
Lenses (standard) per pair
CO-PAYS
$25
SERVICES/FREQUENCY
Exam
Frame
Contact Lens Fitting
Lenses
Contact Lenses
12 months
12 months
12 months
12 months
12 months
Monthly Premiums
Employee Only
Employee + Spouse
Employee+ Child(ren)
Employee + Family
!
$10.28
$18.37
$19.03
$26.48
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 & frames only, not contact lenses.
₂See your benefits materials or definitions of standard & specialty contact lens fittings.
₃Covered to the provider's retail amount for a standard lined trifocal lens; member pays the
difference between the retail price of the progressive lens they have chosen and their
provider's standard lined trifocal lens, plus applicable co-pay
₄Contact lenses are in lieu of eyeglass lenses and frames benefits
This is a general
of your plan
benefits.
Additional
details
on covered
expenses,
limitations
and
exclusions
This is aoverview
general overview
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plan benefits.
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Benefits
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Page 15
The Hartford Disability
Why Do I Need Disability?
Disability is designed to provide a monthly income to an individual who is disabled due to an accident or illness. There are different
plans available with benefits becoming available from the 1st day of disability to as late as the 181st day. Depending upon the
Option selected and the age at which disability occurs, the maximum duration may vary. Carrollton-Farmers Branch ISD offers 2
Disability Options: Premium & Select. All new or increases in coverage are subject to pre-existing condition exclusions.
*The maximum benefit amount you can elect is 66 2/3% of your monthly salary
Option 1: Premium Option
For the Premium Benefit Option – Benefits are payable for disabilities resulting from Sickness or Injury to normal retirement age if
you are disabled prior to age 63. The table below details the applicable benefit duration based on the age you are disabled.
Did You
Premium Option
Age Disabled
Benefits Payable for Disabilities resulting from Sickness or Injury
Prior to Age 63
Age 63
Age 64
Age 65
Age 66
Age 67
Age 68
Age 69 & older
To Normal Retirement Age or 48 months if greater
36 months
30 months
27 months
24 months
21 months
18 months
Know?
Pregnanc
y&
maternity
leave
are a cove
red
disability.
Premium Option Monthly Premiums
Accident / Sickness Elimination Period
Annual
Earnings
Monthly
Earnings
Monthly Disability
Benefit
0/7 day*
14 day*
30 day*
60 day
90 day
180 day
$3,600
$300
$200
$6.80
$6.52
$5.40
$3.96
$3.08
$2.40
$9,000
$750
$500
$17.00
$16.30
$13.50
$9.90
$7.70
$6.00
$18,000
$1,500
$1,000
$34.00
$32.60
$27.00
$19.80
$15.40
$12.00
$27,000
$2,250
$1,500
$51.00
$48.90
$40.50
$29.70
$23.10
$18.00
$36,000
$3,000
$2,000
$68.00
$65.20
$54.00
$39.60
$30.80
$24.00
$45,000
$3,750
$2,500
$85.00
$81.50
$67.50
$49.50
$38.50
$30.00
$54,000
$4,500
$3,000
$102.00
$97.80
$81.00
$59.40
$46.20
$36.00
$63,000
$5,250
$3,500
$119.00
$114.10
$94.50
$69.30
$53.90
$42.00
$72,000
$6,000
$4,000
$136.00
$130.40
$108.00
$79.20
$61.60
$48.00
*For those employees electing an elimination period of 30 days or less, if you are confined to a hospital for 24 hours or
more due to a disability, the elimination period will be waived, & benefits will be payable from the first day of
disability.
Page 16
Option 2: Select Option
For the Select benefit option – Benefits are payable for disabilities resulting from Sickness for 5 years & Injury to normal
retirement age if you are disabled prior to age 63. The table below details the applicable benefit duration based on the
age you are disabled.
Select Option
w?
Age Disabled
Benefits Payable for a Disability Caused by Injury
ers
ord off
tf
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efits W
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Prior to Age 63
Age 63
Age 64
Age 65
Age 66
Age 67
Age 68
Age 69 & older
36 months
30 months
27 months
24 months
21 months
18 months
Age Disabled
Benefits Payable for a Disability Caused by Sickness
Prior to Age 65
Age 65-69
Age 69 & older
5 Years
To Age 70, but not less than 1 year
1 Year
Kno
u
o
Y
id
D
Select Option Monthly Premiums
Accident / Sickness Elimination Period
Annual
Earnings
Monthly
Earnings
Monthly Disability
Benefit
0/7 day*
14 day*
30 day*
60 day
90 day
180 day
$3,600
$9,000
$18,000
$27,000
$36,000
$45,000
$54,000
$63,000
$72,000
$300
$750
$1,500
$2,250
$3,000
$3,750
$4,500
$5,250
$6,000
$200
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$5.60
$14.00
$28.00
$42.00
$56.00
$70.00
$84.00
$98.00
$112.00
$5.28
$13.20
$26.40
$39.60
$52.80
$66.00
$79.20
$92.40
$105.60
$3.96
$9.90
$19.80
$29.70
$39.60
$49.50
$59.40
$69.30
$79.20
$2.88
$7.20
$14.40
$21.60
$28.80
$36.00
$43.20
$50.40
$57.60
$2.24
$5.60
$11.20
$16.80
$22.40
$28.00
$33.60
$39.20
$44.80
$1.76
$4.40
$8.80
$13.20
$17.60
$22.00
$26.40
$30.80
$35.20
*For those employees electing an elimination period of 30 days or less, if you are confined to a hospital for 24 hours or
more due to a disability, the elimination period will be waived, & benefits will be payable from the first day of
disability.
Page 17
Pre-existing Conditions
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 not received treatment for the disabling condition within 3 months, while insured under
this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. 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 we will pay benefits for a maximum of 4 weeks.
Benefit Reductions
Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:
 Social Security Disability Insurance (please see www.mybenefitshub.com/cfbisd for exceptions)
 Workers' Compensation
 Other employer-based Insurance coverage you may have
 Unemployment benefits
 Settlements or judgments for income loss
 Retirement benefits that your employer fully or partially pays for (such as a pension plan.)
Your benefit payments will not be reduced by certain kinds of other income, such as:
 Retirement benefits if you were already receiving them before you became disabled
 Retirement benefits that are funded by your after-tax contributions
 The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement.
Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with
your employer on the day your coverage takes effect.
Exclusions
You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:
 War or act of war (declared or not)
 Military service for any country engaged in war or other armed conflict
 The commission of, or attempt to commit a felony
 An intentionally self-inflicted injury
 Any case where your being engaged in an illegal occupation was a contributing cause to your disability
 You must be under the regular care of a physician to receive benefits.
Mental Illness, Alcoholism and Substance Abuse


You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for
a total of 24 months for all disability periods during your lifetime.
Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness,
alcoholism and substance abuse does not count toward the 24 month lifetime limit.
What other benefits are included in my disability coverage?





Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and
allow you to return to active full-time employment.
Ability Assist— Eligible for services to assist with child/elder care, substance abuse, family relationships. LTD claimants and
their immediate family can receive confidential services to assist with work/life services.
Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to
your spouse or in equal shares to your surviving children under the age of 25, equal to
three times the last monthly gross benefit.
Travel Assistance Program – Provides assistance to employees and their dependents who
travel 100 miles from their home for 90 days or less. Services include pre-trip information,
emergency medical assistance and emergency personal services.
ID Theft Protection—Identity fraud support services, personalized fraud resolution kit and resources, certified caseworker.
Page 18
APL GC-12 Limited Benefit Group Cancer Indemnity Insurance
Carrollton-Farmers Branch Group # 13633
Over 1.7 million new cases of cancer will be diagnosed this year.1 Many major medical insurance policies do not cover all of the expenses related to
the treatment of cancer, which could leave you and your family with unexpected financial expenses. The plan op ons below can help oﬀset some
of the expenses associated with a diagnosis of cancer.
Summary of Benefits*
Base Policy – All benefits are per Covered Person, per Calendar Year unless otherwise stated
Low Op on
High Op on
Cancer Screening Benefits
$75 per test
Follow-Up Diagnos c Tes ng - 1 test per Calendar Year
$50 per test
$100 per test
$100 per test
Medical Imaging – 1 test per Calendar Year
$500 per test
$500 per test
Diagnos c Tes ng - 1 test per Calendar Year
Cancer Treatment Benefits
Radia on Therapy, Chemotherapy or Immunotherapy
Maximum per 12-month period
$15,000
$20,000
$50 per treatment
$50 per treatment
$30 Unit Dollar Amount
Maximum $3,000
per opera on
$45 Unit Dollar Amount
Maximum $4,500
per opera on
25% of amount paid
for covered surgery
25% of amount paid
for covered surgery
Bone Marrow Transplant - Maximum per life me
Stem Cell Transplant - Maximum per life me
$6,000
$600
$9,000
$900
Prosthesis
Surgical Implanta on – 1 device per site, per life me
Non-Surgical (not hair piece) – 1 device per site, per life me
$1,000
$100
$2,000
$200
$100
$200
$100
$200
$200
$400
$400
$800
$200
$30
$400
$40
$100
$100
$200
$400
$100 per day
$200 per day
Donor
Home Health Care
Up to the same number of Hospital Confinement Days
$100 per day
$100 per day
$200 per day
$200 per day
Hospice Care
Up to maximum of 365 days per life me
$100 per day
$200 per day
$100
$100
$200
$400
Hormone Therapy Maximum of 12 treatments per Calendar Year
Surgical Benefits
Surgical
Anesthesia
Pa ent Care Benefits
Hospital Confinement
Per day of Hospital Confinement (1-30 days)
Per day for Eligible Dependent children
Per day of Hospital Confinement (31+ days)
Per day for Eligible Dependent children
Outpa ent Facility - Per day surgery is performed
A ending Physician - Per day of Hospital Confinement
Dread Disease
Extended Care Facility
Up to the same number of Hospital Confinement Days
US Government, Charity Hospital or HMO
summary plan description located on the Carrollton-Farmers Branch ISD Benefits Website: www.mybenefitshub.com/FIELVG
1. American Cancer Society: Cancer Facts and Figures 2014, pg. 1.
Page 19
APESB-449
Underwri en by American Public Life Insurance Company
APL GC-12 Limited Benefit Group Cancer Indemnity Insurance - Group # 13633
Summary of Benefits Continued*
Miscellaneous Benefits
Low Op on
High Op on
Cancer Treatment Center Evalua on or Consulta on - 1 per life me
N/A
$750
Evalua on or Consulta on Travel and Lodging - 1 per life me
Second and Third Surgical Opinion
Second Surgical Opinion
Third Surgical Opinion
N/A
$350
$300 per Diagnosis of Cancer
$150 per Confinement
$50 per Prescrip on
$150
Actual coach fare or
$0.40 per mile
$150 per Confinement
$50 per Prescrip on
$0.40 per mile
$0.75 per mile
$50 per day
$0.40 per mile
$100 per day
$0.75 per mile
$0.40 per mile
$0.75 per mile
Drugs and Medicine
Inpa ent
Outpa ent - Maximum $150 per month
Hair Piece (Wig) - 1 per life me
Transporta on
Travel by bus, plane or train
Travel by car
Maximum of 12 trips per Calendar year for all modes of transportaƟon combined
Lodging - up to a maximum of 100 days per Calendar Year
Family Transporta on
Travel by bus, plane or train
Travel by car
Maximum of 12 trips per Calendar year for all modes of transportaƟon combined
Family Lodging - up to a maximum of 100 days per Calendar Year
Blood, Plasma and Platelets
Experimental Treatment
$150
$0.75 per mile
$50 per day
$100 per day
$300 per day
$300 per day
Paid in the same manner and under the same
maximums as any other benefit
Ambulance
Ground
Air
Maximum of 2 trips per Hospital Confinement for all modes of transportaƟon combined
Inpa ent Special Nursing Services - Per day of Hospital Confinement
Outpa ent Special Nursing Services—Up to same number of Hospital Confinement days
Medical Equipment - Maximum of 1 benefit per Calendar Year
Physical, Occupa onal, Speech, Audio Therapy & Psychotherapy
Maximum per Calendar Year
Waiver of Premium
$200 per trip
$2,000 per trip
$200 per trip
$2,000 per trip
$150 per day
$150 per day
N/A
$25 per visit
$1,000
$150 per day
$150 per day
$150
$25 per visit
$1,000
Waive Premium
Benefit Riders
Internal Cancer First Occurrence Benefit Rider
Lump Sum Benefit
Maximum 1 per Covered Person per life me
Lump Sum for Eligible Dependent Children. Maximum 1 per Covered Person per life me
$5,000
$10,000
$7,500
$15,000
$5,000
$7,500
$10,000
$15,000
$600 per day
$600 per day
$300 per day
$300 per day
Heart A ack/Stroke First Occurrence Benefit Rider
Lump Sum Benefit—Maximum 1 per Covered Person per life me
Lump Sum for Eligible Dependent Children— Maximum 1 per Covered Person per life me
Op onal—Hospital Intensive Care Unit Rider
Intensive Care Unit
Step Down Unit—Maximum of 45 days per Confinement for any combinaƟon of Intensive
Care Unit or Step Down Unit
1. American Cancer Society: Cancer Facts and Figures 2014, pg. 1.
Page 20
APESB-449
APL GC-12 Limited Benefit Group Cancer Indemnity Insurance - Group # 13633
Monthly Premiums*
Low Op on without Op onal—Hospital Intensive Care Unit Rider
Issue Ages
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
18+
$23.12
$49.26
$27.76
$53.88
Low Op on with Op onal—Hospital Intensive Care Unit Rider
Issue Ages
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
18+
$24.84
$52.88
$31.50
$59.52
High Op on without Op onal—Hospital Intensive Care Unit Rider
Issue Ages
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
18+
$39.34
$84.22
$47.36
$92.28
High Op on with Op onal—Hospital Intensive Care Unit Rider
Issue Ages
Individual
Individual & Spouse
1 Parent Family
2 Parent Family
18+
$41.08
$87.84
$51.10
$97.92
*The Premium and amount of benefits provided vary dependent upon the opƟon selected at Ɵme of applicaƟon.
Total premium includes the policy and the benefit riders selected.
APESB-449
Page 21
Lincoln Accident Insurance - Group #404002751
Accident insurance coverage provides a cash benefit when an insured is injured due to a covered accident. Issue ages are 17-80
and coverage is guaranteed renewable. For exclusions and limitations please visit www.mybenefitshub.com/cfbisd
Emergency care
Choice Plan
Ambulance/Air Ambulance
$150/$600
Initial physician office visit/ER visit
Major diagnostic care
$50/$150
$100
Treatment care
Hospital admission
Intensive care daily benefit
Alternate care and rehabilitative
facility daily benefit
Follow-up doctor/patient care up to
6 sessions
Transportation for care (up to 3x
per accident)
Companion lodging (up to 30 days
per accident)
$400
Family care per child (up to 30 days)
$20
Specific injuries or treatments
Choice Plan
Eye (removal of foreign body) once
per eye/accident
Eye (surgical repair) once per eye/
accident
Laceration
Surgery
Surgical repair of, knee cartilage,
rotator cuff, ruptured disc, ligaments/tendons
Dislocations—Partial dislocation
$1,000
$200
Dental extraction once per accident
Per fracture
Chip fractures
Dislocations—per injury
Choice Plan
Hospital confinement daily benefit
Transfusions
Burns
Skin Grafts
Joint replacement
Coma
Concussion
Dental crown once per accident
Fractures
Transitional care benefits
Crutches, wheelchair, walker, other
Prosthesis per limb/device
Reasonable modifications to home or
vehicle
$100
$50
Accidental Death & Dismemberment
(AD&D)
$175
Accidental Death
Employee
Spouse
Child
Loss of or loss of use of one hand, arm,
leg, eye
Loss of or loss of use of any one finger,
thumb, or toe
Common carrier enhanced death benefit
Transportation of remains
Seat belt/helmet AD&D benefit
Common disaster enhanced benefit
Catastrophic loss
Additional Services
Accident EAP services & TravelConnect SM
$100
$150
$100 - $6,400
25% of burn benefit
$1,500-$2,000
$2,000
$100
$150
$50
Nonsurgical/Surgical
$125/$6000
25% of fracture benefit
$125/$3,000
25% of dislocation
benefit
Choice Plan
$25-$350
$500
$2,500
Choice Plan
$30,000
$10,000
$5,000
$7,000
$300
2x benefit amount
$5,000
10% of AD&D
2x benefit amount
$50,000
Choice Plan
Included
$100
$300
$50-$400
$250-$1,000
$300-$400
Monthly Premiums
Employee only
$16.12
Employee + Spouse
$22.54
$27.30
Employee + Family
$36.14
Page 22
Dearborn National® Basic Term Life & AD&D - Group #GAE60152
Carrollton-Farmer’s Branch ISD provides all active, full time employees with Basic Term Life & Accidental Death &
Dismemberment (AD&D) insurance coverage in the amount of $20,000 at no cost to you.
Dearborn National® Supplemental Term Life & AD&D #GAE60152
Employee Coverage
$10,000 increments to a maximum of the lesser of 7 times your basic annual earnings or $500,000.
Life & AD&D benefits reduce by 50% of the original amount at age 70.
Enrollment in this Supplemental Term Life insurance plan will require an Evidence of Insurability for:
Current Employees
 All amounts if you voluntarily canceled your insurance and choose to reapply
 Currently enrolled employees who increase their Supplemental Insurance by more than $20,000
 All amounts for previously eligible employees (and spouse) who did not enroll for Supplemental
Insurance within 31 days of their new hire window.
For New Hires
 Your enrollment takes place within 31 days from the date you become eligible for benefits, and
 You are enrolling for coverage more than $200,000.
Dependent Coverage
Dependents may not have coverage unless the employee has coverage.
If hospitalized, dependent coverage will become effective on the date the eligible dependent is no
longer hospital confined.
Did You
Know?
Dearbor
n Nation
al®
offers o
ther cov
features
Beneficia
& Travel
erage
like
ry Resou
rces
Resource
s.
Spouse- $10,000 increments to a maximum of the lesser of 50% of your Life Benefits or $100,000.
Life & AD&D benefits reduce by 50% of the original amount when the employee turns age 70.
Enrollment in this Supplemental Term Life insurance plan will require an Evidence of Insurability for:
Current Employees
 All increases or new elections for spouse coverage will need to provide additional medical information by completing an
Evidence of Insurability form.
For New Hires
 The enrollment takes place within 31 days from the date you become eligible for benefits, and
 You are enrolling your spouse for coverage more than $50,000.
Dependent Children* - $10,000.
*Child(ren)’s Eligibility: Dependent children ages from live birth to 26 years old are eligible for coverage. If confined to a hospital on
EE Cost per
Spouse Cost** the effective date, coverage will become effective on the
date the dependent is no longer hospital confined. Benefit
Age
$10,000
per $10,000 amount for children age live birth to 6 months is $1,000.
Under 25
25-29
30-34
$0.56
$0.56
$0.74
$0.77
$0.96
$1.15
35-39
$0.74
$1.34
40-44
45-49
50-54
55-59
60-64
65-69
70 & Over
$1.10
$1.46
$2.18
$3.98
$5.06
$9.02
$14.42
$1.53
$2.10
$3.62
$5.71
$10.08
$17.11
$17.11
Cost for your Child(ren)
$1.20
covers all eligible children
Other Coverage Features
Please refer to THEbenefitsHUB
www.mybenefitshub.com/cfbisd for other coverage features:
Conversion
Portability
Beneficiary Resource Services
Travel Resource Services
Waiver of Premium
Accelerated Death Benefit
**spouse rates based on
employee age
the summary plan description located on the Carrollton-Farmer’s Branch ISD Benefits Website: www.mybenefitshub.com/cfbisd
Page 23
Flexible Spending Accounts
A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. Your
contributions are deducted from your pay before taxes are withheld. Because you are taxed on a lower amount of pay, you pay
less in taxes and you have more to spend. You may save as much as 35 percent on the cost of each benefit option! Eligible
expenses must be incurred within the plan year and 75 day grace period and contributions are use-it-or- lose-it. Remember to
retain all your receipts.
NBS WƌĞƉĂŝĚDĂƐƚĞƌĐĂƌĚΠĞďŝƚĂƌĚ
NBS Flexcard – FSA Pre-paid MasterCard
You may use the card to pay merchants or service providers that accept MasterCard credit cards, so there is no need to pay cash
up front then wait for reimbursement.
If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You
must file paper claims or enroll in continual reimbursement.
Current plan participants: You will receive new cards! If you throw away your cards, there is a $5.00 fee to replace them.
New Plan Participants: NBS will mail out your new benefit cards to the address listed in
THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they
should arrive in mid-September. NBS debit cards are good for 3 years
FSA Annual Contribution Max: $2,500
Dependent Care Annual Max: $5,000 ($2,500 for married individuals filing separately).
I enrolled in FSA for the first time, when will I
???
receive my flex card?
Expect Flex Cards to be delivered to the address
listed in THEbenefitsHUB near the end of
September.
Don’t forget, Flex Cards Are Good For 3 Years!
Account Information
Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, ϴ am to ϱ pm Central
Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week
at (801) 838-7324 or toll free (888) 353-9125. For immediate access to your account information at any time, log on to the NBS
website www.NBSbenefits.com Information includes:
Detailed claim history and processing status
Health Care and Dependent Care account balances
Claim forms, Direct Deposit form, worksheets, etc.
Online webclaim
FAQs
For a list of sample expenses, please refer to the C-FBISD benefit website: www.mybenefitshub.com/cfbisd
NBS Contact Information:
8523 South Redwood Road
West Jordan, UT 84088
Phone‐800‐274‐0503
Fax‐800‐478‐1528
Email: claims@nbsbenefits.com
Page 24
Flexible Spending Accounts FAQ
Receive your Dependent Care
Reimbursement Quicker!
A Direct Deposit form is
available on the Benefits
What is a Flexible Spending Account?
A Flexible Spending Account allows you to save money by paying out-of-pocket health and/
or dependent care related expenses with pre-tax dollars. Your contributions are deducted
from your pay before taxes are withheld and your account is up fronted with an annual
amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you
have more to spend.
Website which will help you
get reimbursed quicker!
How does a Flexible Spending Account Benefit Me?
A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care
expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred
within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.
i
What Can I Use My Flexible Spending Account On?
For a full list of eligible expenses, please refer to the www.mybenefitshub.com/cfbisd benefits website, a few examples are below:
Health Care Expense Account Example Expenses:
Acupuncture
Body scans
Breast pumps
Chiropractor
Co-payments
Deductible
Diabetes Maintenance
Eye Exam & Glasses
Fertility treatment
First aid
Hearing aids & batteries
Lab fees
Laser Surgery
Orthodontia Expenses
Physical exams
Pregnancy tests
Prescription drugs
Vaccinations
Vaporizers or humidifiers
Dependent Care Expense Account Example Expenses:

Before and After School and/or Extended Day Programs

The actual care of the dependent in your home.

Preschool tuition.

The base costs for day camps or similar programs used as
care for a qualifying individual.
Tax S
aving
Did You Know?
s on D
epen
dent
Care!
FSAs use tax free
funds to help pay for
your Health Care
Expenses!
What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)?
Eligible expenses must be incurred within the plan year and 75 day grace period. Contributions are use-it-or- lose-it. Remember
to retain all your receipts, receipts may be requested for claim verification.
How Do I File A Claim?
In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to received one you
can visit www.mybenefitshub.com/cfbisd and complete the “Claim Form” to mail or fax to NBS.
This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included
in the summary plan description located on the Carrollton-Farmers Branch ISD Benefits Website: www.mybenefitshub.com/cfbLVG
Page 25
Notes
i
n
This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included
in the summary plan description located on the C-FB ISD Benefits Website: www.mybenefitshub.com/cfbisd

2014 CFBISD summary pages 07.01.14

Transcription

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