Employee Benefits Guide - Hurst-Euless

Transcription

2015-2016
Employee
Benefits Guide
September 1, 2015
through
August 31, 2016
1849 Central Drive, Bedford, TX 76022
Phone (817) 399-2056 | Fax (817) 864-0617
MariaOrtiz@hebisd.edu | www.hebisd.edu
Contact Information
Benefit
Contact #
Website or Email Address
817-399-2056
mariaortiz@hebisd.edu
Fax 817-864-0617
817-399-2056
karenrose@hebisd.edu
Fax 817-864-0617
403b
Contact Name
Maria Ortiz, Benefits
Secretary
Karen Rose, Risk &
Benefits Coordinator
The Omni Group
877-544-6664
www.omni403b.com
457b
RAMS/JEM
800-943-9179
www.region10rams.org
Accidental Death &
Dismemberment Ins
Lincoln Financial
800-423-2765
www.lincolnfinancial.com
Cancer
Allstate - Terry Barber
817-479-0065
Fax 817-605-0084
www.allstatebenefits.com/mybenefits
888-877-7828
www.ldc.lfg.com
800-423-2765
HEB ISD Benefits Office
HEB ISD Benefits Office
Dental – DHMO
Dental – PPO
Group# 982
Group# 40-3002157
Group# 2489
Lincoln Financial
Group# 40-D026226
Lincoln Financial
Low - Group#01-D026217
High- Group# 01-D026225
Dependent Day Care
Reimbursement
TASC
800-422-4661
www.tasconline.com
Disability
The Standard
800-368-1135
www.standard.com
Employee Assistance
Program (EAP)
The Standard
888-293-6948
www.eapbda.com
Flexible Spending Plan
TASC
800-422-4661
www.tasconline.com
Group# 4102-8123-4032
Group# 00-648769-0001
BDA – Bensinger, DuPont
& Assoc.
Group# 4102-8123-4032
GAP Plan
Special Insurance Serv.
Group#27158
800-767-6811
www.specialinc.com
Health Savings Account
HSA Bank
800-357-6246
www.hsabank.com
800-423-2765
Medical – 1HD, 2 or Select Aetna
Pharmacy – 1HD, 2 or Select Caremark
Teladoc – 1HD, 2 or Select Teladoc
800-222-9205
800-222-9205
855-TELADOC
www.trsactivecareaetna.com
www.caremark.com/trsactivecare
Medical – HMO
800-321-7947
www.trs.swhp.org
Life Insurance – Term
Lincoln Financial
Group# 000400175244
Scott & White Health
www.teladoc.com
(enrollment questions)
PrePaid Legal Services
Vision
LegalEase
Superior Vision
Group# 30978
800-248-9000
888-416-4313
www.legaleaseplan.com/content/heb
800-923-6766
www.superiorvision.com
Disclosure
This booklet is intended to only be an overview of the benefits plans offered by Hurst Euless Bedford ISD. Complete details
about how the plans work are included in the plan documents. If there are any inconsistencies between the booklet and
the plan documents, the plan documents will govern. The District reserves the right to change benefits plans at any time.
Please visit www.hebisd.edu and click on Benefits for more detailed documents.
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General Information
PLAN YEAR
The plan year for all benefits is September 1st through August 31st.
EFFECTIVE DATES FOR INSURANCE


Health Insurance can begin your 1st day of employment or the 1st of the following month.
All other benefits will automatically begin the 1st of the monthly following your 1st day of
employment.
NEW HIRES
New hires must enroll in benefits within 30 days of their hire date. Failure to complete elections
during this timeframe will result in the forfeiture of coverage.
ANNUAL ENROLLMENT
During our annual enrollment period (typically held in mid-July through mid-August), 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.
TEACHER RETIREMENT SYSTEM OF TEXAS (TRS)
HEB ISD requires all employees to participate in TRS instead of Social Security. The membership
contribution rate is 7.2% of your annual salary. You may contact TRS by calling 1-800-223-8778 or
www.trs.state.tx.us to learn more about TRS Retirement.
TRS INSURANCE (TRS INS)
Mandatory active member contribution to TRS-Care (Health Insurance for retirees) is .65% of your
annual salary.
EMPLOYEE ELIGIBILITY REQUIREMENTS
Eligible employees must work 20 or more regularly scheduled hours each work week.
ELIGIBLE DEPENDENTS
 Spouse (including common law spouse)
 Child under the age of 26
 Disabled dependent children over the age
documentation of their disability.

of 26 are eligible for benefits if you can provide
Grandchildren are eligible for benefits if you can provide documentation that you are their
legal guardian or that you claimed them as a dependent on your tax return.
The employee is responsible for notifying the Benefits Office when their child no longer meets
the dependent child qualifications.
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PAYCHECKS


Professional and paraprofessional employees receive a paycheck on the 20th of each month.
Auxiliary employees receive a paycheck on the 5th and 20th of each month. One half of your
monthly premium will be taken out of each paycheck.
LEAVES AND ABSENCES - Policy DEC
All full time employees shall earn five paid local leave days and five personal leave days per school
year in accordance with administrative regulations.
An employee shall submit medical certification of the need for leave if the employee is absent more
than four consecutive workdays because of personal illness or illness in the immediate family.
If you need to be out for more than 4 consecutive work days contact:
Karen Rose
Risk & Benefits Coordinator
1849 Central Drive
Bedford, TX 76022
(817) 399-2075 Phone
(817) 354-3589 Fax
karenrose@hebisd.edu
LONG TERM CARE



TRS offers a Long Term Care plan through Genworth Life Insurance Co.
Long Term Care is insurance that will help pay for services provided by Assisted Living
Facilities, Nursing Homes, etc.
If you are interested in enrolling in the Long Term Care plan or have questions, please call
866-659-1970 or visit www.genworth.com/trsactivemember
EMPLOYEE BENEFITS WEB SITE
You can find the most current information and claim forms on the HEB web site. Visit
www.hebisd.edu. Click on Employment then on the left hand side you will click on EMPLOYEE
BENEFITS. This will take you to the Benefits page.
EMPLOYEE ACCESS CENTER
From the Employee Benefits Web Site you can log on to the Access Center to change your address,
view your paycheck stubs, see your current salary and benefit information and much more! Your
login is your 6 digit unique HEB ID number and your default password is your Social Security
Number without the dashes.
EMPLOYEE BENEFITS FACEBOOK
We have created a HEB ISD Employee Benefits Facebook
http://www.facebook.com/hebbenefits and “Like” our page.
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account.
Please
visit
SECTION 125 CAFETERIA PLAN GUIDELINES/FAMILY STATUS CHANGES
A cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance
premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this
benefit. Elections made during annual enrollment will become effective on the plan effective date and
will remain in effect during the entire plan year.
Changes in benefit elections can occur only if you experience a qualifying event. You must:
1. Present proof of a qualifying event to the Benefits Office within 30 days of the qualifying
event and
2. Meet with the Benefits Office to complete and sign necessary paperwork in order to make a
benefit election change.
3. Once your paperwork is received and processed you will receive a confirmation statement
from the Benefits Office. If you do not receive a confirmation statement within 3 days,
contact the Benefits Office immediately!
Benefit changes must be consistent with the qualifying event. As an example, adding or dropping
medical plan dependents is common in the case of birth, marriage, or divorce.
Qualifying events include:
Event
Documentation Needed
Marriage
Marriage License
Divorce
Divorce Decree
Death of spouse/child
Death Certificate
Birth or Adoption of a child
Birth Certificate/Adoption Paperwork
Spouse changes employment resulting in
the gain of employer provided coverage
Written letter on company letterhead
indicating the hire date and the effective
date of your insurance
You, your spouse or child involuntarily
loses health insurance coverage
Documentation from the insurance
company or previous employer indicating
the date the insurance ended
Eligible/ineligible for Medicare/Medicaid
Documentation from Medicare/Medicaid
Change in eligibility status of a dependent
Note indicating the change in eligibility
status
Judgment/decree/order for coverage of
children
Court order
If you do not request a change in benefits within the 30-day period following your qualifying
event, you cannot make changes until the next open enrollment period.
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Workers Compensation
Employee Notice of Alliance Requirements
IMPORTANT CONTACT INFORMATION
To locate a provider, go to www.pswca.org.
To contact your adjuster at the TASB Risk Management Fund, visit www.tasbrmf.org or call (800) 482-7276.
INFORMATION, INSTRUCTIONS, RIGHTS, AND OBLIGATIONS
If you are injured at work, tell your supervisor or employer immediately. The information in this notice will help you to seek medical
treatment for your injury. Your employer will also help with any questions about how to get treatment. You may also contact your
adjuster at the TASB Risk Management Fund (the Fund) for any questions about treatment for a work related injury. The Fund is
your employer’s workers’ compensation coverage provider and they are working with your employer to ensure you receive timely
and appropriate health care. The goal is to return you to work as soon as it is safe to do so.
HOW DO I CHOOSE A TREATING DOCTOR?
If you are hurt at work and you live in the Alliance service area, you are required to choose a treating doctor from the provider list.
This is required for you to receive coverage of healthcare costs for your work related injury. A provider listing is available through
the Alliance website at www.pswca.org and a link to that site is also contained on the Fund’s website at www.tasbrmf.org. It
identifies providers who are taking new patients.
If your treating doctor leaves the Alliance, we will tell you in writing. You will have the right to choose another treating doctor from
the list of Alliance doctors. If your doctor leaves the Alliance and you have a life threatening or acute condition for which a disruption
of care would be harmful to you, your doctor may request that you treat with him or her for an extra 90 days.
WHAT IF I LIVE OUTSIDE THE SERVICE AREA?
If you believe you live outside of the service area, you may request a service area review by calling your adjuster.
HOW DO I CHANGE TREATING DOCTORS?
Within the first 60 days of beginning treatment, if you become dissatisfied with your first choice of a treating doctor, you can select
an alternate treating doctor from the list of Alliance treating doctors in your service area. The Fund will not deny a choice of an
alternate treating doctor. However, before you can change treating doctors a second time, you must obtain permission
from your adjuster.
HOW ARE TREATING DOCTOR REFERRALS HANDLED?
Referrals for health care services that you or your doctor request will be made available on a timely basis as required by your medical
condition. Referrals will be made no later than 21 days after the request. Your doctor should refer you to another Alliance provider
unless it becomes medically necessary to make a referral outside of the Alliance. You do not have to get a referral if you are in need
of emergency care.
WHO PAYS FOR THE HEALTHCARE?
Alliance providers have agreed to seek payment from the Fund for your health care. They should not request payment from you. If
you obtain health care from a doctor who is not in the Alliance without prior approval from your adjuster, you may have to pay for
the cost of that care and your income benefits may be disputed. You may treat with medical providers that are not contracted
with the Alliance only if one of the following situations occurs:
- Emergencies: You should go to the nearest hospital or emergency care facility.
- You do not live within an Alliance service area.
- Your treating doctor refers you to a provider or facility outside of the Alliance. This referral must be approved by your
adjuster.
HOW TO FILE A COMPLAINT
You have the right to file a complaint with the Alliance. You may do this if you are dissatisfied with any aspect of direct contract program
operations. This includes a complaint about the program and/or your Alliance doctor. It may also be a general complaint about the
Alliance. A complainant can notify the Alliance Grievance Coordinator of a complaint by phone, from the Alliance website
www.pswca.org or in writing via mail or fax. Complaints should be forwarded to:
PSWCA (The Alliance)
Attention: Grievance Coordinator
P.O. Box 763
Austin, TX 78767-0763
866-997-7922
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A complaint must be filed with the program grievance coordinator no later than 90 days from the date the issue occurred. Texas
law does not permit the Alliance to retaliate against you if you file a complaint against the program. Nor can the Alliance retaliate if
you appeal the decision of the program. The law does not permit the Alliance to retaliate against your treating doctor if he or she files
a complaint against the program or appeals the decision of the program on your behalf.
WHAT TO DO WHEN YOU ARE INJURED ON THE JOB
If you are injured while on the job, tell your employer as soon as possible. A list of Alliance treating doctors in your service area may
be available from your employer. A complete list of Alliance treating doctors is also available online at www.pswca.org. Or, you may
contact us directly at the following address and/or toll-free telephone number:
TASB Risk Management Fund
P.O. Box 2010
Austin, TX 78768
(800) 482-7276
IN CASE OF AN EMERGENCY…
If you are hurt at work and it is a life threatening emergency, you should go to the nearest emergency room. If you are injured at
work after normal business hours or while working outside your service area, you should go to the nearest care facility. After you
receive emergency care, you may need ongoing care. You will need to select a treating doctor from the Alliance provider list. This
list is available online at www.pswca.org. If you do not have internet access call (800) 482-7276 or contact your employer for a list.
The doctor you choose will oversee the care you receive for your work related injury. Except for emergency care you must obtain all
health care and specialist referrals through your treating doctor.
EMERGENCY CARE DOES NOT NEED TO BE APPROVED IN ADVANCE. “Medical emergency” is defined in Texas laws. It is
a medical condition that comes up suddenly with acute symptoms that are severe enough that a reasonable person would believe
that you need immediate care or you would be harmed. That harm would include your health or bodily functions being in danger or
a loss of function of any body organ or part.
NON-EMERGENCY CARE…
Report your injury to your employer as soon as you can. Select a treating doctor from the Alliance provider list. This list is available
online at www.pswca.org. If you do not have internet access, call 800- 482-7276 or contact your employer for a list.
TREATMENTS REQUIRING ADVANCE APPROVAL
Certain treatments or services prescribed by your doctor need to be approved in advance. Your doctor is required to request approval
from the TASB Risk Management Fund before the specific treatment or service is provided. For example, you may need to stay more
days in the hospital than what was first approved. If so, the added treatment must be approved in advance.
THE FOLLOWING NON-EMERGENCY HEALTHCARE TREATMENT REQUESTS MUST BE APPROVED IN ADVANCE:
Inpatient hospital admissions
Outpatient Surgical or ambulatory surgical services
Spinal Surgery
All non-exempted work hardening
All non-exempted work conditioning
Physical or occupational therapy except for the first six (6) visits if those six visits were done within the first 2 weeks
immediately following date of injury or date of surgery
Any investigational or experimental service
All psychological testing and psychotherapy
Repeat diagnostic studies greater than $350.
All durable medical equipment (DME) in excess of $500
Chronic pain management and interdisciplinary pain rehabilitation
Drugs not included in the TDI Division of Workers’ Compensation Formulary
All narcotic medications dispensed greater than 60 days
Any treatment or service that exceeds the Official Disability Guidelines.
The number your doctor must call to request one of these treatments is 800-482-7276, ext. 6654. If a treatment or
service request is denied, we will tell you in writing. This written notice will have information about your right to request a
reconsideration or appeal of the denied treatment. It will also tell you about your right to request review by an Independent Review
Organization through the Texas Department of Insurance.
7
Sick Leave Bank Summary
P LEASE R EFER TO POLICY DEC (LOCAL). BELOW IS ONLY A GENERAL SUMMARY OF THE POLICY.
•
The purpose of the sick leave bank is to provide additional sick leave days for members of the bank who
have exhausted all available paid leave because of the catastrophic injury or illness of the employee or the
employee’s immediate family member
•
In order to become a member of the sick leave bank, an employee must donate 3 days of local leave.
This is a one-time donation. Additional days may be needed, please see the policy for more details
•
All local sick, state personal, old state and vacation days must be exhausted before days from the sick leave
bank may be used
•
Sick leave bank days are available to use for an employee, spouse, or child’s illness or injury or for a
parent receiving hospice or end-of-life care
•
Employee must be absent for no fewer than 20 workdays in order to be eligible to request days from
the sick leave bank
•
Applications for sick leave bank must be submitted within 15 workdays from the first date of missed work or
15 days prior to the exhaustion of all available leave days
•
Maximum # of days that can be used:
1. Employee’s illness – 30 days per school year
2. Spouse or child’s illness – 30 days per school year; 60 days lifetime maximum
3. Parent -10 days per school year; 20 days lifetime maximum
•
A committee will determine whether the request for sick leave days is approved or denied
•
Qualifying Illness/Injury
1. Catastrophic illness or injury, which is serious in nature, (not a passing disorder or temporary ailment)
requiring treatment by a physician or admittance to a hospital. Although some degree of permanency
is usually involved, the disease need not necessarily be incurable or permanent. Examples may
include, but not be limited to cancer, heart disease, multiple sclerosis, and stroke
2. Complications of pregnancy and childbirth that pose an immediate medical threat
3. Cancer-related intermittent treatment (i.e. chemo, radiation)
•
Members of the bank who, during the previous school year, found it necessary to use the benefits of the
bank must donate three days or the actual number of days used, whichever is less, at the beginning of the
next school year.
Not Covered:
1. Procedure that could be scheduled, without detriment to the employee’s health, at a time more
compatible with the member’s work responsibilities (i.e. Spring Break, Summer, Christmas Break)
2. Pre-existing Conditions – Absences caused by conditions existing at the time of application for bank
membership will not be covered for one year from the date of enrollment in the bank
3. Examples of conditions that are not covered – Hysterectomy, joint replacement (hip, knee, shoulder,
etc.), general illness (flu, cold, etc.), non-complicated pregnancy, broken bone, general surgery, etc.
8
Employee Benefits
Employee Assistance Program
rneStandard
Pointing You ln The Right Direction
Free/No Cost
We all experience times when we need a little help managing our personal
lives. Your employer understands this and is providing the Employee
Assistance Program (EAP)to covered employees in connection with
your group insurance from The Standardt, to offer support, guidance
and resources to help you and your family find the right balance between
your work and home life.
Call 888.293.6948 or visit
www.eapbda.com.
The EAP is always ready to
assist you. We've also
provided a handy reference
card for your wallet.
What Gan The EAP Do For Me?
Experienced master's-degreed clinicians will confidentially consult with you
over the telephone and direct you to the solutions and resources you need.
You may also receive referrals to support groups, community resources,
a network counselor or your health plan. These services are available for
covered employees, their dependents, including children to age 26, and all
household members.
How To Access EAP 0nline
1
.
Enter this address in your Web browser:
wwweapbda.com
The EAP Services Can Help With:
. Child care and elder care
. Alcoholand drug abuse
. Life improvement
. Difficulties in relationships
. Stress and anxiety with work or family
. Depression
. Goal-setting
. Emotionalwell-being
. Financialand legal concerns
. Grief and loss
. ldentity theft and fraud resolution
. Online will preparation
2.
Enter standard as the login lD (in all lowercase letters)
when prompted.
3.
Enter eap4u as the password (in all lowercase letters)
when prompted.
I
o/f,1
Note: lt is a violation of your company's contract to share
this information with individuals who are not eligible for
this service.
I
I
__
Fotd
EAP For Policyholders of The Standard
Call this
toll{ree number for access
to EAP services.
888.293.6948
TDD 800.327.1833
Available 24 hours a day, 365 days a year.
How Do I Access EAP Services?
Follow the directions on the wallet card on this page.
ls lt Confidential?
Your calls and all counseling services are confidential. lnformation will be
released only with your permission or as required by law.
continued on reverse
This EAP service is not affiliated with The Standard. The EAP servrce
+
is
Standard lnsurance Gompany
The Standard Life lnsurance
Company of New York
not an insurance product.
The Standard is a marketing name for StanCorp Financial Group, lnc. and subsidiaries. lnsurance products are
offered by Standard lnsurance Company of l100 SW Sixth Avenue, Portland, ore., in all states except New york,
where insurance products are offered by The Standard Life lnsurance Company of New York of 360 Hamilton
Avenue, Suite 21 0, White Plains, NY. Product features and availability vary by state and company, and are solely
the responsibility of each subsidiary. Each company is solely responsible for its own financial condition. Standard
lnsurance Company is licensed to solicit insurance business in all states except New York. The Standard Life
lnsurance Company of New York is licensed to solicit insurance busrness in only the state of New york.
9
www.standard.com
Employee Assistance Program-3
17201 (5/14) S|/SNY EE
When ls The EAP Available?
Over-the-phone consultation and online access to EAP services
are always available. Simply call the toll-free number or log on to
www.eapbda.com. ln emergency situations, you may callthe toll-free
number to speak with a master's-degreed clinician who can also connect
you to emergency services.
Your program also includes up to three face-to-face assessment and
consultative sessions per issue. A clinician will work with you to schedule
appointments according to your needs.
What Gan Worklife Services Do For Me?
Worklife services can save you countless hours by researching and
providing referrals for important needs like:
'
. Child care and elder care
. Education
. Adoption
. Pet care
. Daily living
. Travel
A broad range of educational materials and guide books on dependent
care topics are also available.
How Much Does lt Cost?
The EAP and Worklife services are provided to you in connection with your
employer-sponsored group insurance from The Standard. lf you accept a
referral to services that are not a part of your EAP program, you may be
responsible for the costs associated with those services.
Al! The Help You Need Online
The EAP provides the following online services:
. lnformative guides and articles
. Monthly webinars and bulletins
. Ability to search on your own for:
- Child care or elder care services
- Pet care
-
Adoption resources
. Detailed maps for every search
. Self-assessments
. Healthy lifestyle guidance, from tools for diet and fitness to smoking cessation
. Videos and articles on topics like understanding depression, nutrition
advice and preparing for childbirth
.
Financial and legal information, including a program for completing a
simple will and identity theft consultation recovery and prevention services
.
Detailed calculators used to help solve common financial concerns, such
as computing college finances
10
Health Insurance
TRS ActiveCare (Aetna)
800-222-9205 www.trsactivecareaetna.com
HMO (Scott & White Health Plan)
800-321-7947 www.trs.swhp.org
In Network Benefits
ActiveCare 1-HD
ActiveCare Select
Scott & White HMO
(Participant Pays)
(Participant Pays)
Deductible must be met
before benefits are paid
No out of network
benefits
No out of network
benefits
$1,200 individual
$3,600 family
$800 individual
$2,400 family
(Participant Pays)
Medical Benefits
Deductible
Maximum Out of Pocket
(Includes medical & prescription
deductibles, coinsurance & copays)
$2,500 Employee Only
$5,000 Employee &
Spouse; Employee &
Children; or Family
$6,450 Employee Only
$12,900 Employee &
Spouse; Employee &
Children; or Family
Coinsurance
20%
Participant pays (after deductible)
Office Visit Copay
Preventive Care
$6,600 individual
$13,200 family
20%
(after deductible)
Plan pays 100%
(Excludes deductible)
(Participant Pays)
$1,000 individual
$3,000 family
$6,600 individual
$13,200 family
20%
20%
20%
$30 copay - Primary
$60 copay - Specialist
$20 copay - Primary
$30 copay - Primary
Plan pays 100%
Plan pays 100%
Plan pays 100%
Diagnostic Lab
20%
(after deductible)
High-tech Radiology
20%
(after deductible)
Quest Facility-Plan
pays 100%;
Other Facility-20%*
$100 copay & 20%*
Outpatient Surgery
20%
(after deductible)
Emergency Room
20%
Inpatient Hospitalization
20%
Teladoc
$5,000 individual
$10,000 family
ActiveCare 2
20%*
Quest Facility-Plan
pays 100%;
Other Facility-20%*
$100 copay & 20%*
$150 copay & 20%*
$150 copay & 20%*
$150 copay & 20%*
(after deductible)
$150 copay & 20%*
$150 copay & 20%*
$150 copay & 20%*
(after deductible)
$150 copay/day & 20%*
$150 copay/day & 20%*
$150 copay/day & 20%*
$40 consultation fee
Plan pays 100%
Not covered
Plan pays 100%
Subject to medical
deductible
$200 per person
(excludes generic)
Retail Maint. 90-Days
$100 per person
(excludes generic)
(excludes generic)
20%*
Prescription Drugs
Drug Deductible
Generic
Brand (preferred list)
Brand (non-preferred list)
20%
20%
20%
(after deductible)
Specialty Drugs
20%
Monthly Premiums
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
(after deductible)
$25
$45
$50 $105
50%
$3
$6
$6
30% 30% 30%
50%
$20 $25
$40 $50
$65 $80
(after deductible)
20%
Tier I-10%, Tier II-20%
Tier III-30%, Tier IV-50%
31 day supply: $200
32-90 day supply: $450
$248
$897
$537
$1,106
$278.60
$910.62
$573.30
$1,034.76
$389
$1,253
$767
$1,296
(after deductible)
$20
$40
$200 per person
$116
$689
$390
$1,006
*After the Deductible has been met
$45
$105
$180
**Qualifies as a high deductible health plan; therefore, you may enroll in a Health Savings Account. See
the Health Savings Account page for more details.
11
2015–2016 TRS-ActiveCare Plan Highlights
Effective September 1, 2015 through August 31, 2016 | Network Level of Benefits*
ActiveCare 1-HD
Type of Service
ActiveCare Select or ActiveCare
Select – Aetna Whole Health
ActiveCare 2
(Baptist Health System and HealthTexas
Medical Group; Baylor Scott & White Quality
Alliance; Memorial Hermann Accountable
Care Network; Seton Health Alliance)
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/any prescription
drug deductible and applicable copays/coinsurance)
$6,450 employee only
$12,900 employee and spouse; employee
and child(ren); employee and family
$6,600 individual
$13,200 family
$6,600 individual
$13,200 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
Participant pays
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)
Participant pays
• Generic copay
• Brand copay (preferred list)
• Brand copay (non-preferred list)
$20
$40***
50% coinsurance
$20
$40***
$65***
Retail Maintenance
(after first fill; up to a 31-day supply)
Participant pays
• Generic copay
$25
$50***
50% coinsurance
$25
$50***
$80***
Mail Order and Retail-Plus
(up to a 90-day supply)
Participant pays
• Generic copay
$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)
12
2015–2016 TRS-ActiveCare Plan Highlights
TRS-ActiveCare Plans – Preventive Care
Preventive Care Services
Network Benefits
When Using Network Providers
(Provider must bill services as “preventive care”)
ActiveCare 1-HD
ActiveCare Select or
ActiveCare Select – Aetna
Whole Health
ActiveCare 2 Network
(Baptist Health System and
HealthTexas Medical Group; Baylor
Scott & White Quality Alliance;
Memorial Hermann Accountable Care
Network; Seton Health Alliance)
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.
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; performed by an opthalmologist or optometrist using
calibrated instruments)
Participant pays
After deductible, plan pays 80%;
participant pays 20%
Annual Hearing Examination
Participant pays
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 or ActiveCare Select – Aetna Whole Health.
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; there is no coverage for
non-network benefits under the Aetna Select Plan; 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 maybe 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.
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
13
by Caremark.
Teladoc
1-855-Teladoc (1-855-835-2362)
www.teladoc.com/trsactivecare
Only available to those enrolled in TRS ActiveCare Health Insurance
Feel better fast . . .
It’s simple. Teladoc provides access to U.S. board-certified
physicians who can resolve most non-emergent medical
issues via phone or online video.
<10 MINUTE
Talk to a doctor
24/7/365, anywhere
MEDIAN CALL BACK TIME
HOW IT WORKS
STEP 1: CONTACT TELADOC 24/7/365
Access to Teladoc’s nationwide network
of board certified physicians is available via
phone, video or mobile app.
STEP 2: TALK WITH A PHYSICIAN
A physician will review the patient’s medical
history and contact them within minutes.
STEP 3: RESOLVE THE ISSUE
A physician will diagnose and prescribe
medication, if medically necessary,
electronically to the pharmacy of choice.
TELADOC PHYSICIANS ARE
U.S. board-certified in internal medicine, family practice,
emergency medicine or pediatrics • State-licensed •
U.S. residents who average 20 years of experience.
14
. . . when you need care!
Teladoc is a convenient alternative to urgent care or ER visits.
U.S. board-certified physicians are available anytime, anywhere,
and can resolve many non emergent medical issues.
PX
DIAGNOSE, TREAT & PRESCRIBE
Teladoc physicians can prescribe medication, when medically
necessary for a wide range of conditions.*
SOME CONDITIONS WE TREAT INCLUDE
GENERAL
HEALTH
DERMATOLOGY
BEHAVIORAL
HEALTH
Talk to a doctor
within minutes.
A specialist at
your fingertips.
Counselling on your
terms
Cold & Flu systems
Skin Infection
Stress/Anxiety
Bronchitis
Acne
Depression
Allergies
Skin rash
Addiction
Pink eye
Abrasions
Domestic Abuse
Urinary tract infection
Moles/Warts
Grief Counselling
Respiratory infection
And more!
And more!
Sinus problems
Ear infection
And more!
* Teladoc physicians do not prescribe substances controlled by the DEA, non-therapeutic, and/or certain other
drugs which may be harmful because of potential for abuse.
15
Scott & White Health Plan
Summary of Benefits for HMO
Plan Provisions
Annual Deductible
Annual out-of-pocket
maximum (including medical and pre-
scription co-pays and co-insurance)
Lifetime Paid Benefit Maximum
Fully Covered Health Care Services
Co-Payment
$800 Individual/
$2,400 Family
LiveWell! Condition Guidance
and Wellness Programs
No Charge
Well Child Care Annual Physicals
No Charge
Immunizations (age appropriate)
No Charge
Outpatient Services
Primary Care
Specialty Care
Pre-Natal Care
Inpatient Delivery
Inpatient Services
Overnight hospital stay: includes
all medical services including
semi-private room or intensive care
Diagnostic &
Therapeutic Services
Physical and Speech Therapy
Equipment and Supplies
Ambulance and Helicopter
$40 co-pay and 20% of charges
after deductible
Emergency Room
$150 co-pay and 20% of charges
after deductible
$55 co-pay
Specialty Medications
Co-Payment
Tier 2 (Preferred)
$20 co-pay
Tier 3 (Premium preferred)
$50 co-pay
Tier 4 (Non-preferred)
50% after deductible3
Maternity Care
$20 co-pay
Urgent Care Facility
Co-Payment
Diagnostic/Radiology
Procedures
Outpatient Surgery
No Charge — go to
trs.swhp.org
20% after deductible1
Allergy Serum & Injections
1-877-505-7947
Tier 1
Other Outpatient Services
Eye Exam (one annually)
Co-Payment
After Hours Primary Care Clinics
Co-Payment
No Charge
$50 co-pay
LiveWell! Online Services
None
No Charge
Home Health Care Visit
LiveWell! Nurse On Call
(excludes deductible)
Standard Lab and X-ray
Co-Payment
Worldwide Emergency Care
$5,000 Individual/
$10,000 Family
Preventive Services
Home Health Services
Prescription Drugs
Annual Benefit Maximum
No Charge
Unlimited
Deductible
$100
Does not apply to generic drugs
$150 co-pay and 20% of
charges after deductible
Ask a SWHP Pharmacy
representative how to
save money on your
prescriptions.
Co-Payment
No Charge
Preferred Generic4
$150 per day2 and
20% of charges
after deductible
Co-Payment
$150 per day2 and
20% of charges
after deductible
(Up to a 34-day supply)
SWHP Pharmacies Only
(Up to a 90-day supply)
$3 co-pay
$6 co-pay
Preferred Brand
Non-preferred
Non-formulary
Greater of $50 or
Not available
Mail Order
Online Refills
Co-Payment
Maintenance Quantity
Retail Quantity
1-800-707-3477
trs.swhp.org
Includes other services, treatments, or procedures received at time of office visit.
$750 maximum co-payment per admission and 20% after deductible.
3
Tier 4 co-payment does not count toward out-of-pocket maximum.
4
If a brand name drug is dispensed when a generic is available, 50% co-pay applies.
1
2
$50 co-pay
Co-Payment
Diabetic Supplies and Equipment
Same as DME or Rx,
as appropriate
Durable Medical Equipment/
Prosthetics
16
trs.swhp.org
Maximum Annual Costs 2015-2016
Hurst Euless Bedford ISD
For Illustration Purposes Only
EMPLOYEE ONLY
Deductible (Medical)
Deductible (Prescription)
Maximum Out of Pocket (co-ins & copays)
Subtotal Medical & Prescription Costs
Annual Premium
Total Premium, Medical & Prescription
Expenses
EMPLOYEE & SPOUSE
Annual Premium
Expenses
EMPLOYEE & CHILD(REN)
ASSUMES 2 CHILDREN
Annual Premium
Expenses
EMPLOYEE & FAMILY
ASSUMES 4 FAMILY MEMBERS
Annual Premium
Expenses
ActiveCare
1 - HD
$2,500
$0
$3,950
$6,450
$1,392
ActiveCare
Select
$1,200
$200
$5,200
$6,600
$2,976
Scott & White
HMO
$800
$100
$5,000
$5,900
$3,343
ActiveCare
2
$1,000
$200
$5,400
$6,600
$4,668
$7,842
$9,576
$9,243
$11,268
ActiveCare
1 - HD
$5,000
$0
$7,900
$12,900
$8,268
ActiveCare
Select
$2,400
$400
$10,400
$13,200
$10,764
Scott & White
HMO
$1,600
$200
$10,000
$11,800
$10,927
ActiveCare
2
$2,000
$400
$10,800
$13,200
$15,036
$21,168
$23,964
$22,727
$28,236
ActiveCare
1 - HD
ActiveCare
Select
Scott & White
HMO
ActiveCare
2
$5,000
$0
$7,900
$12,900
$4,680
$3,600
$600
$9,000
$13,200
$6,444
$2,400
$300
$10,000
$12,700
$6,880
$3,000
$600
$9,600
$13,200
$9,204
$17,580
$19,644
$19,580
$22,404
ActiveCare
1 - HD
ActiveCare
Select
Scott & White
HMO
ActiveCare
2
$5,000
$0
$7,900
$12,900
$12,072
$3,600
$800
$8,800
$13,200
$13,272
$2,400
$400
$10,000
$12,800
$12,417
$3,000
$800
$9,400
$13,200
$15,552
$24,972
$26,472
$25,217
$28,752
17
Split Premiums/Pooling Funds Comparison
TRS ActiveCare
 Married couples working for different participating entities
OR
 Married couples both working for HEB ISD
 Family coverage and all want the same plan; One employee will decline coverage
and the other employee will elect Family coverage
 May “pool” their funds
 Requires an Application to Split Premium form to be completed by both employees
and both employers
Employee & Family
Standard Funding
Employee Only Premium
Employee & Child(ren) Premium
Pooling Funds
Employee & Family Total Premium
HEB Contribution for Employee A
HEB Contribution for Employee B
Total Premium due
Each employee pays
Monthly Savings or (additional cost)
Annual Savings or (additional cost)
TRS ActiveCare
1 -HD
$116.00
$390.00
$506.00
TRS ActiveCare
Select
$248.00
$537.00
$785.00
Scott & White
HMO
$278.60
$573.30
$851.90
TRS ActiveCare
2
$389.00
$767.00
$1,156.00
TRS ActiveCare
1-HD
$1,231.00
-$225.00
-$225.00
$781.00
÷2
$390.50
TRS ActiveCare
Select
$1,331.00
-$225.00
-$225.00
$881.00
÷2
$440.50
Scott & White
HMO
$1,259.76
-$225.00
-$225.00
$809.76
÷2
$404.88
TRS ActiveCare
2
$1,521.00
-$225.00
-$225.00
$1,071.00
÷2
$535.50
($275.00)
($3,300.00)
($96.00)
($1,152.00)
$42.14
$505.68
$85.00
$1,020.00
18
GAP Plan
Special Insurance Services, Inc.
800-767-6811
…the solution to your benefit
problems
If you were hospitalized today, how much do you think your out-of-pocket expenses would be?
Your total expense, including deductible & coinsurance, could be as high as $6,250 or more!
Benefit Connection is a low-cost program designed to help you pay for covered out-of-pocket expenses you
may incur while you are either confined in a hospital or being treated as an out-patient for an injury or an
illness. Please note this plan cannot be used in conjunction with a Health Savings Account (HSA).
Basic Plan Benefits offered to employees of HEB ISD
Hospital Confinement Benefit* - This benefit is designed to offset the cost you incur as an in-patient in the
hospital when your primary comprehensive major medical policy applies such expenses to your deductible or
coinsurance maximum, up to the $1,500 calendar year maximum per insured person.
Out-Patient Benefit* - This benefit offsets the cost you incur for out-patient treatment when your primary
major medical policy applies such expenses to your deductible or coinsurance maximum, up to the $1,500
benefit limit, and up to a maximum of three out-patient occurrences per family per calendar year. An
“occurrence” is the treatment, or the series of treatments, for a specific injury or illness within a calendar
year. Expenses related to physician office visits are not included in this benefit. Covered expenses include:
Surgery in an Out-Patient Facility or a Physician’s Office
Emergency Room visits
Diagnostic testing, Lab & X-ray at a diagnostic or hospital out-patient facility or at a Physician’s office if
the cost is not included in the global office visit fee and is not part of wellness/preventive care
*For expenses to be eligible under this plan they must be medically necessary for the treatment of an injury or illness. Expenses not
covered by your group major medical plan are not covered.
How to File a Claim
When you enroll in the Benefit Connection plan, you will receive an ID card, along with specific instructions on how to
file a claim. This form outlines the procedures you should follow to obtain a claim form, what you need to file a claim,
and where you should send your claim. Simply stated, you will need to submit a completed claim form, itemized bills
(NOT balance due statements), and EOB’s that correspond to the itemized bills.
Claims may be filed at any time, but must be filed no longer than 12 months from the date of service in order to be
eligible for coverage.
Under Age 40
Employee Only
Employee & Spouse
Employee & Family
Rates
$26.89
$49.44
$64.64
$86.57
Ages 40-49
Employee Only
Employee & Spouse
Employee & Family
$35.41
$65.05
$69.58
$98.44
Ages 50 & Above
Employee Only
$74.37
Employee & Spouse
$136.65
Employee & Child(ren) $128.15
Employee & Family
$188.80
This information sheet highlights the important features of the product. The policy has limitations and exclusions. The exact provisions governing
the insurance are contained in the master policy issued to each group on form number GAPP-4200, policy series G4200. Your carrier representative
can supply you with costs and complete details of coverage.
19
Dental Plans
PPO – Lincoln Financial Group (800) 423-2765
DHMO – Lincoln Financial Group (888) 877-7828
www.ldc.lfg.com
The district offers a choice of 3 different dental plans. A summary of the respective plans follows.
DHMO
PPO
High
PPO
Low
Preventive Services
Fixed Co-Pays
Plan Pays 100%
Plan Pays 100%
Basic
Fixed Co-Pays
Plan Pays 80%
Plan Pays 70%
Fixed Co-Pays
Plan Pays 50%
Plan Pays 50%
Fixed Co-Pays
Plan Pays 50%
Not Covered
Ortho. Lifetime Maximum
N/A
$1,000
Not Covered
Out of Network Benefits
No
Yes
Yes
Out of Network Reimbursement
None
90th Percentile
Based on Contracted
Fee Schedule
Deductible (Per Calendar Year)
None
$50 Person
$150 Family
$25 Person
$75 Family
None
$1,000
$750
Yes – See the next 2
pages for list of dentists
No
No
$1 - $600
$1 - $300
$250 per year
$150 per year
$350 per year
$200 per year
$1,000
$750
(Cleanings, Exams, X-Rays, etc.)
(Fillings, Extractions, etc.)
Major
(Crowns, Bridges, Dentures, etc.)
Orthodontics (Children under 19)
Annual Maximum Benefit
(Maximum amount the insurance company
will pay during a calendar year)
Primary Care Dentist Required
Deductible Applies
Deductible Applies
Deductible Applies
Deductible Applies
MaxRewards
Eligible Range (Claim Threshold)
Rollover Amount
Rollover Amount with Preferred
Provider
Not Applicable
Maximum Rollover Account Balance
Premiums
Employee Only
$13.91
$38.00
$25.00
Employee + 1
$26.42
$75.50
$51.50
Employee + Family
$41.72
$114.50
$69.50
*Note: Please refer to the plan booklets for specific fixed co-pays for DHMO.
20
Dental Providers for the DHMO Plan
TARRANT COUNTY
ARLINGTON
DIAMOND DENTAL
CARE
(817)-563-1111
4050 W I 20
ARLINGTON, TX 76017
-TURNER, CECIL
Prov. No.: 22949
MILESTONE DENTAL
(817) 635-6453
5005 S COOPER ST.
SUITE 173
ARLINGTON, TX 76017
-AHMED, SULLMAN
Prov. No.: 4474714
-ALLES, RODNEY
Prov. No.: 1554381
-ANDERSON, RYAN
Prov. No.: 2782425
-CASSIDY, CHRISTOPHER
Prov. No.: 8359036
-CASTLE, MICHAEL
Prov. No.: 3915219
MONARCH DENTAL
(817)-795-4044
1005 N COLLINS ST
STE 100
ARLINGTON, TX 76011
-ARRECHEA, VANINA C.
Prov. No.: 000002020063
-COLEMAN, DEBRA Y.
Prov. No.: 000000213995
-MEHTA, SALIL
Prov. No.: 000002088546
-MOORE, MICHAEL B.
Prov. No.: 000001121691
-MOORE, ROLAND E.
Prov. No.: 000001121689
MONARCH DENTAL
(817)-561-9199
5760 W PLEASANT
RIDGE RD STE 110
ARLINGTON, TX 76016
-CARMICHAEL, BRYAN
Prov. No.: 7194445
-COUGHLIN, CHRISTINE
Prov. No.: 6299204
-JEMELKA, JOE F.
Prov. No.: 000000031309
-KRYSIAK, AMANDA
Prov. No.: 11551469
-MEHTA, SALIL
Prov. No.: 000002018052
-JOSEPH, CATHY
Prov. No.: 000000716276
-MUKHERJI, PARTHA
Prov. No.: 000001548246
-CHAUDHARI, REKHA
Prov. No.: 12108012
-RHOADS, STANLEY
Prov. No.: 3913713
-WORLTON, SCOTT
Prov. No.: 12017399
-WILLIAMS, KIMBERLY
Prov. No.: 11774011
SERENITY DENTAL SPA
(817) 277-1871
696 N FIELDER RD.
SUITE 104
ARLINGTON, TX 76012
-JAMES, LEON
Prov. No.: 6299448
BRIDENT DENTAL
(682)-560-4468
3779 S COOPER ST
ARLINGTON, TX 76015
-CHANG, SZU-WEI
Prov. No.: 000002298619
-JAFFER, SALMAN
Prov. No.: 000002298934
-KUNG, ANDREW
Prov. No.: 000002298542
-PATEL, TANVIBEN J.
Prov. No.: 000002450929
-SEN, SOUMAVA
Prov. No.: 000002299254
EULESS
MONARCH DENTAL
(817)-540-2252
1201 W AIRPORT FWY
#299
EULESS, TX 76040
-KHAMAS, SARMAD
Prov. No.: 12099854
-AL-DARKAZALI, AWS
Prov. No.: 12100565
BRIDENT DENTAL
(682) 999-3116
2142 N COLLINS ST.
ARLINGTON, TX 7611
BRIDENT DENTAL
(817)-786-3941
1101 N MAIN ST
EULESS, TX 76039
-CHANG, SZU-WEI
Prov. No.: 11551878
-GADE, ANURADHA
Prov. No.: 11551895
-KUNG, ANDREW
Prov. No.: 11551893
-LEE, ANNA
Prov. No.: 11551890
-NGUYEN, DAVID
Prov. No.: 12005055
-AHIR, DHIREN
Prov. No.: 10902896
-BHADESHIYA, HARDIK
Prov. No.: 11998836
-CHAE, ANTHONY S.
Prov. No.: 000002450675
-CHANG, SZU-WEI
Prov. No.: 000002298613
-MARTINEZ, GINALYN
Prov. No.: 4474220
-RABATA, AHMAD
Prov. No.: 12130740
-JAFFER, SALMAN
Prov. No.: 2298908
-SHYAM, SONYA
Prov. No.: 12103626
-PARK, JAMES
Prov. No.: 11551271
Prov. No.: 10903409
-HAENDEL, JACLYN
Prov. No.: 1657056
-TRUONG, PETER
Prov. No.: 2299484
-NGUYEN, DAVID
Prov. No.: 2299605
-SILVA OSEGUERA,
ANTONIO
Prov. No.: 2449524
BEDFORD
BRANSON DENTAL
Prov. No.: 35325
(817)-285-8825
1220 F AIRPORT FWY
BEDFORD, TX 76022
MONARCH DENTAL
(817)-540-2223
1717 AIRPORT FWY
BEDFORD, TX 76021
-AMIN, AWESTA
Prov. No.: 12005330
Prov. No.: 6299207
-EDWARDS, CHRISTOPHER
Prov. No.: 11773599
HURST
BRADLEY, CHARLES
Prov. No.: 000000126662
489 W HARWOOD RD
HURST, TX 76054
(817)-282-9161
CASTLE DENTAL
(817)-268-4867
1101 MELBOURNE ST
#7002
HURST, TX 76053
-JOSEPH, CATHY
Prov. No.: 000000716287
-NELSON, GARRETT
Prov. No.: 000011997857
-COLEMAN, DEBRA
Prov. No.: 12046713
-WILLIAMS, KIMBERLY
Prov. No.: 11774005
-WORLTON, SCOTT
Prov. No.: 12017403
-KHAMAS, SARMAD
Prov. No.: 12099855
BRIDENT DENTAL
(682) 253-3146
1460 PRECINCT LINE RD
STE 300
HURST, TX 76054
-AHIR, DHIREN
Prov. No.: 8359268
-BHADESHIYA, HARDIK
Prov. No.: 11998857
-CHAE, ANTHONY S.
Prov. No.: 6510724
-CHANG, SZU-WEI
Prov. No.: 10596155
-PARK, JAMES
Prov. No.: 12000499
-SHYAM, SONYA
Prov. No.: 12103663
-JAYSWAL, NIKI
Prov. No.: 12116299
-NGUYEN, DAVID
Prov. No.: 12005049
-LEE, ANNA
Prov. No.: 12005899
-KUNG, ANDREW
Prov. No.: 6510725
-PATEL, DEVANG
Prov. No.: 6511157
-LEE, JOON
Prov. No.: 6510990
This is not a complete list and is subject to change. For the most current list, please visit Lincoln Financial’s website and
search for DHMO Dentists.
21
FORT WORTH
ACCESS DENTAL
(817)-446-0800
6302 MEADOWBROOK
#112
FORT WORTH, TX 76112
-PHAN,TIEN D.
Prov. No.: 000000438383
ACCESS DENTAL
(214)-391-1900
6901 MCCART AVE
STE 175
-PHAN, TIEN D.
Prov. No.: 000000459791
DRAKE, LEIGH G.
(817)-877-4600
Prov. No.: 000000070924
1120 S HENDERSON
I SMILE DENTAL PA
(817) 253-6169
5824 S HULEN ST
-TRUONG, THANH N.
Prov. No.: 000000328244
MITCHELL, EARL A.
Prov. No.: 000000087948
1511 E BERRY ST
(817)-924-7171
MONARCH DENTAL
(817)-921-1544
4200 S FWY STE 15
-AZANGUE, LAURIANT
Prov. No.: 000001211790
-BRANCA, NICOLE
Prov. No.: 1215183
-DAVILA, MICHELLE
Prov. No.: 10904059
-KRYSIAK, AMANDA
Prov. No.: 12000837
-MEHTA, SALIL
Prov. No.: 6811880
WEST TEXAS DENTAL
(817) 457-4141
6600 BRENTWOOD
STAIR ROAD
MONARCH DENTAL
(817)-346-9040
6261 GRANBURY RD
-CARR, TONI
Prov. No.: 16909
-CHRISTENSEN, MARK
Prov. No.: 11994625
-POQUIZ, JANE
Prov. No.: 000000031319
-RAMIZHIRJI, RAFIQ
Prov. No.: 000001957001
-STEWART, KANIKA S.
Prov. No.: 000001822252
-DEZHAM, HOSSAIN
Prov. No.: 418623
GRAPEVINE
MONARCH DENTAL
(817)-251-0057
306 S PARK BLVD
STE 120
GRAPEVINE, TX 76051
BRIDENT DENTAL
(817) 344-7159
3411 SYCAMORE
SCHOOL RD
-BUDHANI, AAMIR
Prov. No.: 000000736705
-EDWARDS,
CHRISTOPHER
Prov. No.: 11773601
-HOANG, AUSTIN
Prov. No.: 000001132882
-PALHAN, SHALU
Prov. No.: 000001054693
-XU, JEAN J.
Prov. No.: 000001215657
-WILLIAMS, KIMBERLY
Prov. No.: 11774012
-AHIR, DHIREN
Prov. No.: 6963871
-CHAE, ANTHONY
Prov. No.: 6510741
-GADE, ANURADHA
Prov. No.: 11116050
-PARK, YOUNA
Prov. No.: 10404193
-PATEL, DEVANG R.
Prov. No.: 6511158
NRH
MONARCH DENTAL
(817)-918-3010
8528 DAVIS BLVD
STE 100
NRH, TX 76180
-AMIN, AWESTA
Prov. No.: 12005326
-EDWARDS,
CHRISTOPHER
Prov. No.: 11773602
-ELAM, MAEGAN
Prov. No.: 000002159479
-HORNER, SANDRA T.
Prov. No.: 000000364767
-KRYSIAK, AMANDA
Prov. No.: 12000506
MONARCH DENTAL
(817)-918-3030
6455 HILLTOP DR
STE 114
NRH, TX 76180
-JAMES, LEON D.
Prov. No.: 000001265557
-KENNEY, DANIEL
Prov. No.: 4029982
-HORNER, SANDRA
Prov. No.: 10120003
KELLER
BRIDENT DENTAL
(817)-585-2475
6000 CAMP BOWIE BLVD
#120
MILESTONE DENTAL
(817) 581-6453
5800 N TARRANT PKWY
STE 102
KELLER, TX 76244
-CHANG, SZU-WEI
Prov. No.: 000002298618
-JAFFER, SALMAN
Prov. No.: 000002298929
-KUNG, ANDREW
Prov. No.: 000002298541
-PARK, YOUNA
Prov. No.: 000002449535
-PATEL, DEVANG R.
Prov. No.: 000002373531
-ALLES, RODNEY
Prov. No.: 3915869
-ANDERSON, RYAN
Prov. No.: 2782427
-GEIGER, COURTNEY
Prov. No.: 2782997
-HERMAN, SARAH
Prov. No.: 12007836
-ZERBY, WILLIAM
Prov. No.: 6964077
-HATTAWAY, RICHARD
Prov. No.: 12093869
-PADUA, MARIE
Prov. No.: 12059686
-REAGAN, JAMES
Prov. No.: 12110315
-AGUILAR, JONATHAN
Prov. No.: 12120019
-SELEZNEVA, OLGA
Prov. No.: 12145745
BRIDENT DENTAL
(817) 918-3295
4511 WESTERN CENTER
BLVD.
-AHIR, DHIREN
Prov. No.: 10902898
-CASSIDY, CHRISTOPHER
Prov. No.: 4249868
-KIM, MIN
Prov. No.: 7193084
-LEE, ANNA
Prov. No.: 12005893
-PARK, JAMES
Prov. No.: 12000495
OLSON, MARSHALL
Prov. No.: 12029993
777 BANDIT TRAIL
KELLER, TX 76248
(817)-427-2622
22
SOUTHLAKE
IDEAL DENTAL
(817) 421-9999
2645 E SOUTHLAKE
BLVD, SUITE 150
SOUTHLAKE, TX 76092
-AGUILAR, JONATHAN
Prov. No.: 12120024
-ALLES, RODNEY
Prov. No.: 10215641
-HERMAN, SARAH
Prov. No.: 12007981
-JACKSON, ASHLEY
Prov. No.: 11331671
-MCCAMMON, DUSTIN
Prov. No.: 12004893
-REAGAN, JAMES
Prov. No.: 12110102
-HATTAWAY, RICHARD
Prov. No.: 12093866
-VILLARREAL, MARCOS
Prov. No.: 12119868
-DAY, MARTHA
Prov. No.: 12149457
-MINOR, LINDSAY
Prov. No.: 12029052
-LOVING, DAN
Prov. No.: 12029053
-STRUMWASSER, BRETT
Prov. No.: 12007980
-HERMAN, SARAH
Prov. No.: 12007981
Schedule of Benefits for DHMO Plan
Code
Service
Diagnostic Treatment
D0120
Periodic Oral Evaluation
D0150
Comprehensive Oral Evaluation - New Or Established Patient
D0210
X-Rays Intraoral - Complete Series - Including Bitewings
D0274
X-Rays Bitewings - Four Films
D0330
Panoramic Film
Preventive Services
D1110/D1120 Prophylaxis - Adult and Child
D1351
Sealant per tooth
Restorative Services
D2140
Amalgam - One Surface, Primary Or Permanent
D2330
Resin-Based Composite - One Surface, Anterior
D2391
Composite (White) Filling - One Surface - Posterior Tooth
Crowns
D2740
Crown Porcelain/Ceramic Substrate
D2751
Crown Porcelain Fused To Predominantly Base Metal
Endodontics
D3220
Therapeutic Pulpotomy
D3330
Root Canal - Molar - Per Tooth
Periodontics
D4260
D4341
Osseous Surgery (Inc Flap Entry) - Four Or More Contiguous Teeth Or Bounded Teeth
Spaces - Per Quadrant
Periodontal Scaling And Root Planning - Four Or More Contiguous Teeth Or Bounded
Teeth - Per Quadrant
D4381
Localized Delivery Of Antimicrobial Agents
D4910
Periodontal Maintenance
Prosthodontics
D5110/D5120 Complete Denture - Maxillary / Mandibular
D5211/D5212 Partial Denture - Resin Base - Maxillary / Mandibular
Crowns / Fixed Bridges
D6241
Pontic - Porcelain Fused To Predominantly Base Metal
D6750
Porcelain Crown Fused To High Noble Metal
Oral Surgery
Extraction, Erupted Tooth Or Exposed Root (Elevation And / Or Forceps
D7140
Removal)
D7210
Surgical Removal Of Erupted Tooth
D7220
Removal Of Impacted Tooth - Soft Tissue
D7240
Extraction - Removal Of Impacted Tooth - Completely Bony
Orthodontic
s
D8070,
Comprehensive Orthodontic Treatment Of The Transitional, Adolescent Or
D8080,
Adult Dentition
D8090
Start-up fee (Including exam, beginning records, x-rays, tracing, photos, &
D8999
models)
Adjunctive General Services
D9110
Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure
D9220
DP Sedation/Gen Anesthesia – 1st 30 Minutes
D9310
Consultation
D9972
External Bleaching – Per Arch
D0999
Office Visit Fee - Per Visit
Copayment
$0
$0
$0
$0
$0
$0
$5
$0
$0
$35
$210
$150
$0
$225
$275
$35
$55
$25
$215
$250
$150
$150
$0
$15
$35
$75
$1,895
$250
$10
$145
$0
$125
$5
***This benefit comparison is for illustration purposes only. See schedule of benefits for details.
23
DENTAL PPO Plans
•
•
•
•
•
You may choose any dentist. However, using contracting dentists should lower your out-of-pocket
expenses. * You do not need a referral to see a specialist. A list of participating dentists may be
accessed at www.LincolnFinancial.com.
By enrolling in the dental plan you and your enrolled family members will have access to Lincoln
DentalConnectSM, our free on-line dental health information Web site.
If you incur dental expenses, the plan pays the following percentage of allowable expenses in excess
of the deductible up to the maximum benefit.
Covered dental expenses include only those services listed in your certificate.
Covered expenses outside the panel service area will not exceed the policy’s usual and
customary allowances.
PPO High Plan
Preventive
Basic
Major
Orthodontics
Deductible
Maximum
Ortho Maximums
Exclusions
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Routine Oral Exams
Routine Cleanings
Fluoride Treatments
Sealants
X-Rays
Space Maintainers
Fillings
Simple Extractions
Surgical Extractions
Denture Repair
Non-surgical Periodontal Therapy
Periodontal Surgery
Oral Surgery
Anesthesia
• Full & Partial Dentures
• Endodontics (including Root Canal
Treatment)
• Crowns, Inlays, Onlays & related services
• Orthodontic Treatment – including
Orthodontic Exams, X-rays, Extractions,
Study Models & Appliances
Calendar year deductible. Waived for
Preventive Services
Calendar year maximum for Preventive, Basic
& Major Services
Lifetime Ortho Maximum for Children
PPO Low Plan
Routine Oral Exams
Routine Cleanings
Fluoride Treatments
Sealants
X-Rays
Space Maintainers
Fillings
Simple Extractions
Surgical Extractions
Denture Repair
Non-surgical Periodontal Therapy
Periodontal Surgery
Oral Surgery
Anesthesia
Endodontics (including Root Canal
Treatment)
• Full & Partial Dentures
• Crowns, Inlays, Onlays & related services
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Not Covered
Calendar year deductible. Waived for
Preventive Services
Calendar year maximum for Preventive, Basic &
Major Services
Not Covered
This is a summary of policy exclusions. The policy contains other, more specific, exclusions and limitations not fully
explained in this benefit summary.
•
•
Plan benefits are not payable for a condition for which the claimant is eligible for benefits under worker’s
compensation or a similar law; or for a condition attributed to employment or military service. Coverage is not
available for dental conditions caused by an act of war, self-inflicted injury, involvement in an illegal occupation;
attempt to commit a felony, or active participation in a riot.
If benefits for orthodontia are included, the plan does not cover any treatment plan started before coverage begins
or during the benefit waiting period unless the member was receiving orthodontia benefits from this employer’s
previous group dental policy. In that case, Lincoln Financial will continue orthodontia benefits until the combined
benefit paid by the two policies is equal to this policy’s lifetime orthodontia.
24
PPO Dental M a x R e w a r d s Program
M ax im ize your Lincoln DentalConnect plan benefits
The MaxRewards maximum rollover feature allows covered members to roll over a portion of their
unused annual maximum into a MaxRewards Account Balance. This flexibility lets members save for
more expensive dental treatment down the road.
How the M ax R ew ards feature w ork s
To qualify for a rollover, a covered member must meet the following qualifications during the year:
• Submit at least one claim for covered services
• Keep benefit payments during the year below the threshold amount
If eligible, the rollover amount is moved into the member’s MaxRewards Account Balance. The member
can use the MaxRewards Account for future covered services when the plan’s annual maximum is
exhausted.
M ax R ew ards benefits
Promotes better oral health by requiring an annual treatment to be eligible for rollovers
Empowers members to manage benefit dollars they would lose under a traditional plan
Allows members to build up their MaxRewards Account Balance in order to cover large claims
Rewards long-term members by allowing the rollover account to accumulate over time
Includes a bonus amount when members seek care from in-network providers, with the
option to remove the in-network bonus amount
 Offers high threshold amounts with the option to remove threshold and claim requirements





The M ax R ew ards feature in action
Plan specifications and hypothetical scenario
Annual
maximum
$1,000
Threshold
$600
Claim
required?
Yes
Out of network rollover
In-network
rollover
MaxRewards Account
$250
$350
$1,000
Balance limit
YEAR 1 Member uses $300 toward the $1,000 annual maximum and sees an out-of-network dentist at least once.
• The $300 benefit is less than the $600 threshold, so the member is eligible for a rollover.
• Since the member saw an out-of-network dentist at least once, the out-of-network rollover amount of $250 is
deposited into the MaxRewards Account Balance.
YEAR 2 Member has $1,000 annual maximum and $250 in her MaxRewards Account Balance, and uses zero dollars
toward the annual maximum (she didn’t see the dentist).
• The plan design requires at least one claim in the calendar year for any rollover amount to be applied.
• Since no claims were incurred this year, the plan applies no rollover amount.
• The member still has $250 in her MaxRewards Account Balance from the prior year rollover.
YEAR 3 Member has $1,000 annual maximum and $250 in her MaxRewards Account Balance, and incurs $1,100 in
claims from an in-network dentist.
• The $1,100 claim cost is above the $1,000 maximum, so $100 of the MaxRewards Account Balance is applied to cover
the remaining cost.
• Since the annual claim costs are above the $600 threshold, the claimant is not eligible for a rollover benefit.
• $150 remains in the member’s MaxRewards Account Balance for future use.
25
Vision Plan
Superior Vision
800-923-6766 www.superiorvision.com
Copays
Eye Exam Copay
Material Copay (lenses & frames only, not contact lenses)
Contact Lens Fitting
$10
$25
$0 (Standard) / $50 retail allowance (Specialty)
Benefits (In Network)
Frames
Contact Lenses
$130 retail allowance; 20% off amount over allowance
Single Vision, Bifocal & Trifocal Lenses
Covered in full
Progressive Lens upgrade
Covered to provider’s in-office standard retail lined trifocal amount;
member pays difference between progressive & standard retail lined
trifocal, plus applicable co-pay
Factory scratch coat
Covered in full
(in lieu of eyeglass lenses & frames benefit)
$150 retail allowance
Services/Frequency (Based on date of service)
Exam
Frames
Contact Lens Fitting
Lenses
Contact Lenses
12
24
12
12
12
Discounts on Covered Materials
months
months
months
months
months
Discount Features
The following options have out-of-pocket maximums on Standard (no premium, brand, or progressive) lenses.
Maximum Member Out-of-Pocket
Single Vision
Bifocal & Trifocal
$13
$13
$15
$15
$25
$25
$50
$50
$40
20% off retail
$55
20% off
$80
20% off
Scratch coat
Ultraviolet coat
Tints, solid or gradients
Anti-reflective coat
Polycarbonate
High index 1.6
Photochromic
Discounts on Non-Covered Exam & Material
Exams, frames & prescription lenses
Lens options, contacts, other prescription materials
Disposable contact lenses
Refractive Surgery
30% off
20% off
10% off
Superior Vision has a nationwide network of refractive surgeons
and leading LASIK networks who offer members a discount. These
discounts range from 5% - 50%, and are the best possible
discounts available to Superior Vision.
Monthly Premiums
Employee Only
Employee + 1
Employee + Family
$6.10
$11.84
$17.39
26
Disability Insurance
The Standard 800-368-1135 www.standard.com
What if you weren’t getting a paycheck?
Chances are work plays an important role in your life. So what if a disabling illness or
injury kept you from the workplace? How long would your savings hold out?
Certainly, there’s a lot depending on your paycheck. That’s why HEB ISD has teamed up
with The Standard to offer disability income protection insurance. Should a disability
prevent you from working and earning a living, this insurance can help you meet your
expenses.
What is Disability Income?
It replaces a portion of your income when you are sick or injured and cannot work.
1st Step: Select a Benefit Amount –
You may purchase any monthly benefit amount in $100 increments up to 2/3rds of your
monthly earnings.
2nd Step: Choose a Benefit Waiting Period that meets your needs –
Benefit waiting period is the period of time that you must be continuously disabled before
benefits become payable. Benefits are NOT payable during the benefit w aiting
period. Options: 0/ 7, 14, 30, 60, 90, 180 days
First Day Hospital Benefit:
With this benefit, if an insured employee is admitted as a hospital inpatient for at least four
hours during the Benefit Waiting Period, the Benefit Waiting Period will be satisfied. Benefits
become payable on the date of the hospitalization. This feature is included only on plans
w ith a Benefit W aiting P eriod of 30 days or less.
Preexisting Condition Exclusion:
Any condition you had 90 days prior to the effective date of your insurance will be considered
preexisting. The exclusion period is 12 months.
Preexisting Condition Waiver:
For the first 90 days of disability, The Standard will pay full benefits even if you have a
preexisting condition.
Other Features:
Employee Assistance Program (EAP) - This program offers support, guidance and resources
that can help an employee resolve personal issues and meet life’s challenges.
27
Standard Insurance Company
Educator Options Voluntary Long Term Disability
Coverage Highlights – Texas
Hurst Euless Bedford Independent School District
Options 1-6: Maximum Benefit Period To Age 65 for both Sickness & Accident
Monthly
Annual Monthly Disability
Earnings Earnings Benefit
Accident/Sickness Benefit Waiting Period
Cost Per Month
0-7
14-14
30-30
60-60
90-90
180-180
3,600
300
200
9.74
7.78
6.42
4.38
3.80
2.94
5,400
450
300
14.61
11.67
9.63
6.57
5.70
4.41
7,200
600
400
19.48
15.56
12.84
8.76
7.60
5.88
9,000
750
500
24.35
19.45
16.05
10.95
9.50
7.35
10,800
900
600
29.22
23.34
19.26
13.14
11.40
8.82
12,600
1,050
700
34.09
27.23
22.47
15.33
13.30
10.29
14,400
1,200
800
38.96
31.12
25.68
17.52
15.20
11.76
16,200
1,350
900
43.83
35.01
28.89
19.71
17.10
13.23
18,000
1,500
1,000
48.70
38.90
32.10
21.90
19.00
14.70
19,800
1,650
1,100
53.57
42.79
35.31
24.09
20.90
16.17
21,600
1,800
1,200
58.44
46.68
38.52
26.28
22.80
17.64
23,400
1,950
1,300
63.31
50.57
41.73
28.47
24.70
19.11
25,200
2,100
1,400
68.18
54.46
44.94
30.66
26.60
20.58
27,000
2,250
1,500
73.05
58.35
48.15
32.85
28.50
22.05
28,800
2,400
1,600
77.92
62.24
51.36
35.04
30.40
23.52
30,600
2,550
1,700
82.79
66.13
54.57
37.23
32.30
24.99
32,400
2,700
1,800
87.66
70.02
57.78
39.42
34.20
26.46
34,200
2,850
1,900
92.53
73.91
60.99
41.61
36.10
27.93
36,000
3,000
2,000
97.40
77.80
64.20
43.80
38.00
29.40
37,800
3,150
2,100
102.27
81.69
67.41
45.99
39.90
30.87
39,600
3,300
2,200
107.14
85.58
70.62
48.18
41.80
32.34
41,400
3,450
2,300
112.01
89.47
73.83
50.37
43.70
33.81
43,200
3,600
2,400
116.88
93.36
77.04
52.56
45.60
35.28
45,000
3,750
2,500
121.75
97.25
80.25
54.75
47.50
36.75
46,800
3,900
2,600
126.62
101.14
83.46
56.94
49.40
38.22
48,600
4,050
2,700
131.49
105.03
86.67
59.13
51.30
39.69
50,400
4,200
2,800
136.36
108.92
89.88
61.32
53.20
41.16
52,200
4,350
2,900
141.23
112.81
93.09
63.51
55.10
42.63
54,000
4,500
3,000
146.10
116.70
96.30
65.70
57.00
44.10
55,800
4,650
3,100
150.97
120.59
99.51
67.89
58.90
45.57
57,600
4,800
3,200
155.84
124.48
102.72
70.08
60.80
47.04
59,400
4,950
3,300
160.71
128.37
105.93
72.27
62.70
48.51
61,200
5,100
3,400
165.58
132.26
109.14
74.46
64.60
49.98
63,000
5,250
3,500
170.45
136.15
112.35
76.65
66.50
51.45
64,800
5,400
3,600
175.32
140.04
115.56
78.84
68.40
52.92
66,600
5,550
3,700
180.19
143.93
118.77
81.03
70.30
54.39
68,400
5,700
3,800
185.06
147.82
121.98
83.22
72.20
55.86
70,200
5,850
3,900
189.93
151.71
125.19
85.41
74.10
57.33
72,000
6,000
4,000
194.80
155.60
128.40
87.60
76.00
58.80
28
SI 14494-648769
(3/14)
Voluntary Long Term Disability Insurance
Standard Insurance Company has developed this document to provide you with information about the optional
insurance coverage you may select through the Hurst Euless Bedford Independent School District. Written in nontechnical language, this is not intended as a complete description of the coverage. If you have additional questions,
please check with your human resources representative.
Employer Plan Effective Date
The group policy effective date is September 1, 2011.
Eligibility
To become insured, you must be:
 A regular employee of the Hurst Euless Bedford Independent School District, excluding temporary or seasonal
employees, full-time members of the armed forces, leased employees or independent contractors
 Actively at work at least 20 hours each week
 A citizen or resident of the United States or Canada
Employee Coverage Effective Date
Please contact your human resources representative for more information regarding the following requirements that
must be satisfied for your insurance to become effective. You must satisfy:
 Eligibility requirements
 An eligibility waiting period of the first day of the month that follows the date you become an eligible employee
 An evidence of insurability requirement, if applicable
 An active work requirement. This means that if you are not actively at work on the day before the scheduled
effective date of insurance, your insurance will not become effective until the day after you complete one full day
of active work as an eligible employee.
Benefit Amount
You may select a monthly benefit amount in $100 increments from $200 to $8,000; based on the tables and
guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not
exceed 66 2/3 percent of your monthly earnings.
Benefits are payable for non-occupational disabilities only. Occupational disabilities are not covered.
Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings
Plan Minimum Monthly Benefit: 10 percent of your LTD benefit before reduction by deductible income
29
SI 14494-648769
(3/14)
Benefit Waiting Period and Maximum Benefit Period
The benefit waiting period is the period of time that you must be continuously disabled before benefits become
payable. Benefits are not payable during the benefit waiting period. The maximum benefit period is the period for
which benefits are payable. The benefit waiting period and maximum benefit period associated with your plan
options are shown below:
Option
1
2
3
4
5
6
Accidental Injury
0 days
14 days
30 days
60 days
90 days
180 days
Other Disability
7 days
14 days
30 days
60 days
90 days
180 days
Maximum Benefit Period
To Age 65 for both Sickness and Accident
Options 1-6: Maximum Benefit Period To Age 65 for Sickness and Accident
If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you
become disabled at age 62 or older, the benefit duration is determined by your age when disability begins:
Age
62
63
64
65
66
67
68
69+
3 years 6 months
3 years
2 years 6 months
2 years
1 year 9 months
1 year 6 months
1 year 3 months
1 year
First Day Hospital Benefit
With this benefit, if an insured employee is admitted as a hospital inpatient for at least four hours during the Benefit
Waiting Period, the Benefit Waiting Period will be satisfied. Benefits become payable on the date of
hospitalization; the maximum benefit period also begins on that date. This feature is included only on LTD plans
with Benefit Waiting Periods of 30 days or less.
Preexisting Condition Exclusion
A general description of the preexisting condition exclusion is included in the Group Voluntary Long Term
Disability Insurance for Educators and Administrators brochure. If you have questions, please check with your
human resources representative.
Preexisting Condition Period: The 90-day period just before your insurance becomes effective
Exclusion Period: 12 months
Preexisting Condition Waiver
For the first 90 days of disability, The Standard will pay full benefits even if you have a preexisting condition. After
90 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply.
Own Occupation Period
For the plan’s definition of disability, as described in your brochure, the own occupation period is the first
24 months for which LTD benefits are paid.
Any Occupation Period
The any occupation period begins at the end of the own occupation period and continues until the end of the
maximum benefit period.
30
SI 14494-648769
(3/14)
Other LTD Features
 Employee Assistance Program (EAP) – This program offers support, guidance and resources that can help an
employee resolve personal issues and meet life’s challenges.
 Special Dismemberment Provision – If an employee suffers a lost as a result of an accident, the employee will
be considered disabled for the applicable Minimum Benefit Period and can extend beyond the end of the
 Reasonable Accommodation Expense Benefit – Subject to The Standard’s prior approval, this benefit allows us
to pay up to $25,000 of an employer’s expenses toward work-site modifications that result in a disabled
employee’s return to work.
 Survivor Benefit – A Survivor Benefit may also be payable. This benefit can help to address a family’s financial
need in the event of the employee’s death.
 Return to Work (RTW) Incentive – The Standard’s RTW Incentive is one of the most comprehensive in the
employee benefits history. For the first 12 months after returning to work, the employee’s LTD benefit will not
be reduced by work earnings until work earnings plus the LTD benefit exceed 100 percent of predisability
earnings. After that period, only 50 percent of work earnings are deducted.
 Rehabilitation Plan Provision – Subject to The Standard’s prior approval, rehabilitation incentives may include
training and education expense, family (child and elder) care expenses, and job-related and job search expenses.
When Benefits End
LTD benefits end automatically on the earliest of:
 The date you are no longer disabled
 The date your maximum benefit period ends
 The date you die
 The date benefits become payable under any other LTD plan under which you become insured through
employment during a period of temporary recovery
 The date you fail to provide proof of continued disability and entitlement to benefits
Rates
Employees can select a monthly LTD benefit ranging from a minimum of $200 to a maximum amount based on
how much they earn. Referencing the appropriate attached charts, follow these steps to find the monthly cost for
your desired level of monthly LTD benefit and benefit waiting period:
1. Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or
Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum
amount you can receive. If your earnings fall between two amounts, you must select the lower amount.
2. Select the desired monthly LTD benefit between the minimum of $200 and the determined maximum amount,
making sure not to exceed the maximum for your earnings.
3. In the same row, select the desired benefit waiting period to see the monthly cost for that selection.
If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the
premium payment of your desired benefit, please contact your human resources representative.
Group Insurance Certificate
If you become insured, you will receive a group insurance certificate containing a detailed description of the
insurance coverage. The information presented above is controlled by the group policy and does not modify it in
any way. The controlling provisions are in the group policy issued by Standard Insurance Company.
31
SI 14494-648769
(3/14)
Cancer Insurance
Allstate – Terry Barber
817-479-0065
www.allstatebenefits.com/mybenefits
Group Voluntary Cancer Insurance
If you suddenly become diagnosed with cancer, it can be difficult on your family’s financial and
emotional stability. Having the right coverage to help when you are sick and undergoing
treatment or when you cannot work is important. Our cancer insurance can help provide security
when you need it most.
Meeting Your Needs
Our cancer coverage can help offer you and your family members’ financial support during a
period of unexpected illness.
• Benefits will be paid directly to you unless otherwise assigned
• Coverage can be purchased for you or your entire family
• Waiver of premium after 90 days of disability due to cancer as long as your disability
lasts
• Portable coverage
• Includes coverage for 29 other specified diseases
,S[XS+IX%GGIWW
LEWRIZIVFIIRIEWMIV
*MPI'PEMQW
'LIGOGPEMQWXEXYW
+IXFIRIJMXGSZIVEKIHIXEMPW
6IZMI[GPEMQWLMWXSV]
1EOIGLERKIWXSTIVWSREPMRJSVQEXMSR
+SSRPMRIXS 7MKRYTJSVEGGIWWYWMRKXLIWIGYVISRPMRIVIKMWXVEXMSR
TVSGIWW'VIEXIE9WIV-(ERH4EWW[SVH
&ITVITEVIHXSTVSZMHI]SYV77^MTGSHIERH
FMVXLHEXI
2IIHLIPTVIKMWXIVMRK#.YWXGPMGOSRw2IIH,IPT" MRXLI QIRYXSXLIVMKLX
3RGIVIKMWXIVIHJYPPEGGIWWXSEPPFIRIJMXWERH[IFWMXI
MWEZEMPEFPIHE]SVRMKLXMXvWXLEXWMQTPI
32
•Allstate.
Group benefit coverage for:
BENEFITS
group voluntary cancer
HOSPITAL AND RELATED BENEFITS
Continuous Hospital Confinement (daily)
LOW
$200
HIGH
$200
Government or Charity Hospital (daily)
$200
$200
Private Duty Nursing Services (daily)
$200
$200
Extended Care Facility (daily)
$200
$200
At Home Nursing (daily)
Hospice Care Center (daily) or
Hospice Care Team (per visit)
$200
$200
1. $200
2. $200
1. $200
2. $200
RADIATION, CHEMOTHERAPY AND RELATED BENEFITS
Radiation/Chemotherapy for Cancer (every 12 mos.)
$10,000'
$20,000*
Blood, Plasma, and Platelets (every 12 mos.)
$10,000*
$20,000*
$500*'
$1,000*'
$200*
$400*
$3,000*'
$3,000''
Medical Imaging (yearly)
Hematological Drugs (yearly)
SURGERY AND RELATED BENEFIT S
Surgery
Anesthesia (% of surgery)
Ambulatory Surgical Center (daily)
Second Opinion
Bone Marrow or Stem Cell Transplant
1. Autologous
2. Non-autologous
3. Non-autologous for leukemia
25%
25%
$500
$500
$400
$400
1. $1,000'
2. $2,500'
3. $5,000'
1. $1,000'
2. $2,500'
3. $5,000'
MISCELLANEOUS BENEFITS
Inpatient Drugs and Medicine (daily)
$25
$25
Physician's Attendance (daily)
$50
$50
Ambulance (per confinement)
$100
$100
Coach Fare
or $0.40
Coach Fare
or $0.40
$50*'
$50*'
Non-Local Transportation (per trip or mile)
Outpatient Lodging (daily)
Family Member Lodging (daily)
and Transportation (per trip or mile)
$50'
Coach Fare
or $0.40
$50*
Coach Fare
or $0.40
$50
$50
Physical or Speech Therapy (daily)
New or Experimental Treatment (every 12 mos.)
$5,000*
$5,000*
Prosthesis
$2,000*3
$2,000*3
Hair Prosthesis (every 2 years)
$25
$25
$50'
$50*
$200*
$200*
Yes
Yes
$2,0005
$5,0005
$100'
$100'
1. $600
2. $300
3. Charges
1. $600
2. $300
3. Charges
Nonsurgical External Breast Prosthesis
Anti-Nausea Benefit (yearly)
Waiver of Premium (primary insured only)
ADDITIONAL BENEFITS
Cancer Initial Diagnosis
Wellness (yearly)
Intensive Care
premiums
1. Intensive Care Confinement (daily)
2. Step-down Confinement (daily)
3. Air/Surface Ambulance
PLAN
EE+ SP
EE
EE+ CH
Listed to the
left are benefit
amounts
associated with
the benefits
described in
the brochure.
' Benefit pays for
charges/costs up
to amount listed
' Limit $2,000/
12 mo. period
'Based on
procedure up to
maximum shown
' Per amputation
' Payable once/
covered person/
calendar year
'One-time benefit
F
Low
$26.41
$4187
$37.28
$52.72
High
$40.33
$63.24
$57.55
$80.44
33
Group benefit coverage for:
Group Cancer Insurance
Supplements existing coverage and can provide
cash to help with medical and living expenses
Group Voluntary Cancer Coverage from Allstate Benefits pays cash benefits
for cancer and 29 specified diseases to help with the costs associated with
treatments and expenses as they happen.
it Allstate
BENEFITS
THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A
SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THE POLICY, AND IF THE EMPLOYER
IS A NON-SUBSCRIBER , THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE
WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS' COMPENSATION LAW
AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
ABJ30082X
34
cancer and specified disease
Receiving a diagnosis of cancer or a specified disease can be difficult on anyone, both emotionally and financially. Having the
right coverage to help when undergoing treatments for cancer or a specified disease is important. Our coverage can help
provide added financial support when it is needed most.
Our coverage helps offer peace of mind when a diagnosis of cancer or a specified disease occurs. Below is an example of
how benefits might be paid.*
Jane chooses benefit
coverage under her
Employer
Approved Plan
Jane undergoes her
annual wellness test and
is diagnosed with cancer.
Jane's doctor recommends pre-op testing
and provides her with the location of the
hospital. Jane must travel 200 miles to
have pre-op testing (medical imaging) and
is admitted to the hospital for surgery.
Jane undergoes surgery, anesthesia,
radiation/chemo, and is visited by a
doctor during a 3-day hospital stay.
And every 2 weeks she has radiation/
chemotherapy at a local facility, is given
anti-nausea medication, and sees her
doctor during her follow-up visits.
Our cancer insurance policy paid Jane the following:
Wellness Exam
$
100
Hospital Confinement
$ 600
Cancer Initial Diagnosis�$�2,_
00_0
_____
Non-Local Transportation $
160
Surgery --$ 3,000
$
750
Anesth�
$10,000
Radiation/Chemo
Medical Imaging
$ 500
Inpatient Mec:ilcTne
$
�
Physician Visits
$
150
$
200
Anti-Nausea
Total Benefits:
$17,535
*The example shown may vary from the plan your employer is offering. Your individual experience may also vary.
meeting your needs
benefit coverage highlights
Our Cancer coverage can help offer you
and your family financial support.
Cancer and specified disease benefits can help cover the costs of
specific treatments and expenses as they happen. Terms and conditions
for each benefit will vary.
• Benefits paid directly to you unless
otherwise assigned
• Coverage for you or your entire family
• No evidence of insurability required
at initial enrollmentt
• Waiver of premium after 90 days of
disability due to cancer for as long as
your disability lasts**
• Portable
I Enrolling after your initial enrollment period
requires evidence of insurability.
" Primary insured only.
Specified Diseases - Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease),
Muscular Dystrophy, Poliomyelitis, Multiple Sclerosis, Encephalitis,
Rabies, Tetanus, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever,
Cerebrospinal Meningitis, Brucellosis, Sickle Cell Anemia, T halassemia,
Rocky Mountain Spotted Fever, Legionnaires' Disease, Addison's Disease,
Hansen's Disease, Tularemia, Hepatitis (Chronic B or C), Typhoid Fever,
Myasthenia Gravis, Reye's Syndrome, Primary Sclerosing Cholangitis
(Walter Payton's Disease), Lyme Disease, Systemic Lupus Erythematosus,
Cystic Fibrosis, and Primary Biliary Cirrhosis.
HOSPITAL AND RELATED BENEFITS
Continuous Hospital Confinement - Pays a benefit for each day of
inpatient confinement.
Government or Charity Hospital - Pays a benefit for each day of
inpatient confinement to a U.S. government hospital or a hospital that
does not charge for its services. In lieu of all other benefits.
Private Duty Nursing Se_rvices - Pays a daily benefit when receiving
physician-authorized inpatient private nursing services.
Extended Care Facility - Pays a daily benefit for physician-authorized
inpatient confinement (within 14 days of a hospital stay).
At Home Nursing - Pays a daily benefit for physician-authorized
private nursing care (up to the number of days of the previous
hospital stay).
35
Wellness tests
annually
October
18
A doctor visit
is scheduled
Hospice Care - Pays a benefit when a physician determines
terminal illness and approves hospice care at home (1 visit
per day) or in a freestanding hospice care center.
RADIATION, CHEMOTHERAPY AND RELATED BENEFITS
Tests are run and
results received
You get
paid cash
Family Member Lodging and Transportation - Pays a
benefit for one adult family member when confined at a
non-local hospital for specialized treatment (more than
100 miles from family member's home).
Radiation/Chemotherapy for Cancer - Pays a benefit for
covered treatment to destroy or modify cancerous tissue.
Physical or Speech T herapy - Pays a daily benefit for
physical or speech therapy to restore normal body function.
Blood, Plasma, and Platelets - Pays a benefit for blood,
plasma, and platelets. Includes charges for transfusions,
administration, processing, procurement and cross-matching.
Does not include donor replaced blood or immunoglobulins.
New or Experimental Treatment - Pays a benefit for
physician-approved new or experimental treatments not
paid under other benefits.
Medical Imaging - Pays a benefit for an initial diagnosis
or follow-up evaluation.
Hematological Drugs - Pays a benefit for drugs to boost cell
lines when Radiation/Chemotherapy for Cancer benefit
is paid.
SURGERY AND RELATED BENEFITS
Surgery*- Pays a benefit for an inpatient or outpatient
operation listed in the Schedule of Surgical Procedures.
Anesthesia - Pays 25% of surgery benefit.
Ambulatory Surgical Center - Pays a benefit for surgery
at an ambulatory surgical center.
Second Opinion - Pays a benefit for a second surgical
opinion.
Bone Marrow or Stem Cell Transplant - Pays a benefit
for transplants.
MISCELLANE OU S BENEFITS
Inpatient Drugs and Medicine - Pays a daily benefit for
inpatient drugs and medicine.
Physician's Attendance - Pays a daily benefit for one
inpatient visit.
Ambulance - Pays a benefit for transfer by ambulance
service to or from a hospital.
Non-Local Transportation - Pays a benefit for transportation
for treatment not available locally (up to 700 miles)
Outpatient Lodging - Pays a daily benefit for lodging when
receiving radiation or chemotherapy on an outpatient
basis non-locally (more than 100 miles from home).
'Two or more surgeries done at the same time are considered one operation.
The operation with the largest benefit will be paid. Outpatient is paid at 150%
of the amount listed in the Schedule of Surgical Procedures.
36
Prosthesis - Pays a benefit for a prosthetic device that
requires surgical implanting.
Hair Prosthesis - Pays a benefit for a wig or hairpiece when
hair loss is experienced.
Nonsurgical External Breast Prosthesis - Pays a benefit
for the initial nonsurgical breast prosthesis after a
covered mastectomy.
Anti-Nausea Benefit - Pays a benefit for prescribed anti
nausea medication administered on an outpatient basis.
Waiver of Premium (primary insured only) - Pays premiums
after disabled 90 days in a row due to cancer, for as long
as disability lasts.
ADDIT ION AL B ENEFIT S
Cancer Initial Diagnosis - Pays a one-time benefit if
diagnosed for the first time with cancer (except skin cancer)
Wellness - Pays a benefit each calendar year for one of the
following: Biopsy for skin cancer; Blood tests for triglycerides,
CA15-3 (breast cancer), CA125 (ovarian cancer), CEA
(colon cancer) and PSA (prostate cancer); Bone Marrow
Testing; Chest X-ray; Colonoscopy; Doppler screening for
carotids or peripheral vascular disease; Echocardiogram;
EKG; Flexible sigmoidoscopy; Hemoccult stool analysis;
HPV (Human Papillomavirus) Vaccination; Lipid panel
(total cholesterol count); Mammography, including Breast
Ultrasound; Pap Smear, including T hin Prep Pap Test; Serum
Protein Electrophoresis (test for myeloma); Stress test on
bike or treadmill; T hermography; and Ultrasound screening
for abdominal aortic aneurysms
Intensive Care - Pays a daily benefit for Intensive Care Unit
Confinements for any illness or accident (up to 45 days for
each stay), Step-down Intensive Care Unit Confinements
(up to 45 days for each stay) and air or surface ambulance
to a hospital intensive care unit.
f
I
Intensive Care Benefits Exclusions and Limitations Ca) Benefits are not paid for: Cl) attempted suicide or
intentional self-inflicted injury; C2) intoxication or being
under the influence of drugs not prescribed by a physician;
or C3) alcoholism or drug addiction. Cb) Benefits are not
paid for confinements to a care unit that does not qualify
as a hospital intensive care unit including progressive care,
subacute intensive-care, intermediate care, private rooms
with monitoring, step-down and other lesser care units.
Cc) Benefits are not paid for step-down confinements in
the following units: telemetry or surgical recovery rooms;
post-anesthesia care; progressive care; intermediate care;
private monitored rooms; observation units in emergency
rooms or outpatient surgery units; beds, wards, or private
or semi-private rooms; emergency, labor or delivery rooms;
or other facilities that do not meet the standards for a
step-down hospital intensive-care unit. Cd) Benefits are not
paid for confinements occurring during a hospitalization
prior to the effective date. Ce) Children born within 10 months
of the effective date are not covered for confinement
occurring or beginning during the first 30 days of the
child's life. CO We do not pay for ambulance if paid under
the cancer and specified disease ambulance benefit.
CERTIFICATE SPECIFICATIONS
Eligibility - Coverage may include you, your spouse or
domestic partner and children under age 26.
Termination of Coverage - Ca) Coverage under the policy
ends on the date the policy is canceled; the last day
premium payments were made; the last day of active
employment, unless coverage is continued due to
Temporary Layoff, Leave of Absence or Family and
Medical Leave of Absence; the date you or your class is
no longer eligible. Cb) Spouse/domestic partner coverage
ends upon divorce/termination of partnership or your
death. Cc) Coverage for children ends when the child
reaches age 26, unless he or she continues to meet the
requirements of an eligible dependent.
Portability Privilege - Coverage may be continued under the
Portability Provision when coverage under the policy ends.
LIMITS, EXCLUSIONS AND EXCEPTIONS
Pre-Existing Condition - Ca) Allstate Benefits does not pay
benefits for a pre-existing condition during the 12-month
period beginning on the date that person's coverage starts.
Cb) A pre-existing condition is a disease or condition for
which symptoms existed within the 12-month period prior
to the effective date; or Cc) medical advice or treatment
was recommended or received from a medical professional
within the 12-month period prior to the effective date.
Cd) A pre-existing condition can exist even though a
diagnosis has not yet been made.
Cancer and Specified Disease Benefits Exclusions and
Limitations - Ca) Allstate Benefits does not pay for any loss,
except for losses due to cancer or a specified disease.
Cb) Benefits are not paid for conditions caused or aggravated
by cancer or a specified disease.
Treatment and services must be needed due to cancer or
a specified disease and be received in the United States
or its territories.
For the Surgery, New or Experimental Treatment and
Prosthesis benefits, Allstate Benefits pays 50% of the
applicable maximum when specific charges are not
obtainable as proof of loss.
For the Radiation/Chemotherapy for Cancer benefit,
Allstate Benefits does not pay for: Ca) any other chemical
substance which may be administered with or in conjunction
with radiation/chemotherapy; or Cb) treatment planning
consultation; management; or the design and construction
of treatment devices; or basic radiation dosimetry calculation;
or any type of laboratory tests; X-ray or other imaging
used for diagnosis or monitoring; or the diagnostic tests
related to these treatments; or Cc) any devices or supplies
including intravenous solutions and needles related to
these treatments.
37
Term Life Insurance
Lincoln Financial 800-423-2765 www.lincolnfinancial.com
Build your benefit with Lincoln Financial‘s Voluntary Life Insurance. Your employer gives you the
opportunity to buy valuable life insurance coverage for yourself or your family – all at affordable group
rates.
Employee
Basic Life
and AD&D
Insurance Schedules
Employee
Spouse
Child
$10,000 Increments
$5,000 Increments
Day 1 to 6 months:
$500
Maximum Benefit
$5,000
5 x Salary to
$500,000
Employee
Contribution
50% of employee’s
Benefit up to
$75,000
0%
100%
100%
100%
Rate per $1,000
No charge
See Step Rates Below
$.120
Guarantee Issue as a
New Hire
$5,000
3 times salary to
$300,000
See Step Rates
Below
$30,000
All Guaranteed Issue
$5,000 or $10,000
Age
Employee Rate per $1,000
Spouse Rate per $1,000
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
$0.024
$0.038
$0.040
$0.053
$0.075
$0.095
$0.136
$0.224
$0.396
$0.572
$1.009
$1.615
$1.544
$1.544
$0.024
$0.038
$0.040
$0.053
$0.075
$0.095
$0.136
$0.224
$0.396
$0.572
$1.009
$1.615
$1.544
$1.544
•
If your spouse works for HEB ISD, your spouse cannot be listed as a dependent on Lincoln Financial’s
supplemental life insurance policy. Both employees have to enroll in his/her own Life Insurance
policy. Children/dependents-only one employee may enroll the dependents under his/her life policy.
•
Coverage is portable. You can take this coverage with you upon retirement or termination.
•
TravelConnect program offers a wealth of travel, medical and safety-related services when you travel
more than 100 miles from home.
38
Voluntary Life Insurance
SUMMARY OF BENEFITS
Sponsored by:
Hurst-Euless-Bedford ISD
Effective date:
September 01, 2013
All Active Full-time Employees
Life Benefit
Employee
Spouse
Amount
Choice of $10,000 increments
Choice of $5,000
increments
Not to exceed 5 times your salary.
Dependent
Choice of $5,000 or
$10,000 child(ren) age 6
months to 26 years.
Day 1 to 6 months: $500
Employee must elect
coverage for spouse to be
eligible. Not to exceed
Employee must elect
50% of employee elected coverage for dependent to
amount.
be eligible.
Minimum Amount
$10,000
$5,000
$500
Maximum Amount
$500,000
$75,000
$10,000
Guarantee Issue
Newly Eligible Employees: The lesser
of $300,000 or 300% of salary of
coverage is available on a guaranteed
acceptance basis.
Current Eligible Employees: Up to 2
Increments are available on a
guaranteed acceptance basis.
Newly eligible spouses:
$30,000 of coverage is
available on a guaranteed
acceptance basis.
Current eligible spouses:
Up to 2 Increments are
available on a guaranteed
acceptance basis.
$10,000
Benefit Reduction
Employee
Spouse
Benefits will reduce: Coverage will terminate upon
retirement.
Benefits will terminate
upon employee retirement.
Additional Benefits
See Definition:
Accelerated Death Benefit
Conversion
Portability
Eligibility
Employee
Spouse and Dependents
All full-time active employees working Cannot be in a period of
20 or more hours per week in an
limited activity on the day
eligible class are eligible for coverage coverage takes effect.
on the policy effective date. A delayed
effective date will apply if the employee
is not actively at work.
ROADURBI
HRST
HRA1D656NA20130304
1.00
39
2013/03/04
Employee Monthly Premium
Voluntary Life Premium for sample benefit amounts
Employee and Spouse premiums are calculated separately.
Spouse premiums will be calculated based on the Employee’s age.
Refer to Program Specifications for your maximum benefit amounts.
AGE
Monthly
Rate per
$1,000
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
<20
$0.024
$0.24
$0.48
$0.72
$0.96
$1.20
$1.44
$1.68
$1.92
$2.16
$2.40
20 - 24
$0.038
$0.38
$0.76
$1.14
$1.52
$1.90
$2.28
$2.66
$3.04
$3.42
$3.80
25 - 29
$0.040
$0.40
$0.80
$1.20
$1.60
$2.00
$2.40
$2.80
$3.20
$3.60
$4.00
30 - 34
$0.053
$0.53
$1.06
$1.59
$2.12
$2.65
$3.18
$3.71
$4.24
$4.77
$5.30
35 - 39
$0.075
$0.75
$1.50
$2.25
$3.00
$3.75
$4.50
$5.25
$6.00
$6.75
$7.50
40 - 44
$0.095
$0.95
$1.90
$2.85
$3.80
$4.75
$5.70
$6.65
$7.60
$8.55
$9.50
45 - 49
$0.136
$1.36
$2.72
$4.08
$5.44
$6.80
$8.16
$9.52
$10.88
$12.24
$13.60
50 - 54
$0.224
$2.24
$4.48
$6.72
$8.96
$11.20
$13.44
$15.68
$17.92
$20.16
$22.40
55 - 59
$0.396
$3.96
$7.92
$11.88
$15.84
$19.80
$23.76
$27.72
$31.68
$35.64
$39.60
60 - 64
$0.572
$5.72
$11.44
$17.16
$22.88
$28.60
$34.32
$40.04
$45.76
$51.48
$57.20
65 - 69
$1.009
$10.09
$20.18
$30.27
$40.36
$50.45
$60.54
$70.63
$80.72
$90.81
$100.90
70 - 74
$1.615
$16.15
$32.30
$48.45
$64.60
$80.75
$96.90
$113.05
$129.20
$145.35
$161.50
75 - 79
$1.544
$15.44
$30.88
$46.32
$61.76
$77.20
$92.64
$108.08
$123.52
$138.96
$154.40
80 - 84
$1.544
$15.44
$30.88
$46.32
$61.76
$77.20
$92.64
$108.08
$123.52
$138.96
$154.40
Spouse Monthly Premium
Voluntary Life Premium for sample benefit amounts
AGE
Monthly
Rate per
$1,000
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
< 20
$0.024
$0.12
$0.24
$0.36
$0.48
$0.60
$0.72
$0.84
$0.96
$1.08
$1.20
20 - 24
$0.038
$0.19
$0.38
$0.57
$0.76
$0.95
$1.14
$1.33
$1.52
$1.71
$1.90
25 - 29
$0.040
$0.20
$0.40
$0.60
$0.80
$1.00
$1.20
$1.40
$1.60
$1.80
$2.00
30 - 34
$0.053
$0.27
$0.53
$0.80
$1.06
$1.33
$1.59
$1.86
$2.12
$2.39
$2.65
35 - 39
$0.075
$0.38
$0.75
$1.13
$1.50
$1.88
$2.25
$2.63
$3.00
$3.38
$3.75
40 - 44
$0.095
$0.48
$0.95
$1.43
$1.90
$2.38
$2.85
$3.33
$3.80
$4.28
$4.75
45 - 49
$0.136
$0.68
$1.36
$2.04
$2.72
$3.40
$4.08
$4.76
$5.44
$6.12
$6.80
50 - 54
$0.224
$1.12
$2.24
$3.36
$4.48
$5.60
$6.72
$7.84
$8.96
$10.08
$11.20
55 - 59
$0.396
$1.98
$3.96
$5.94
$7.92
$9.90
$11.88
$13.86
$15.84
$17.82
$19.80
60 - 64
$0.572
$2.86
$5.72
$8.58
$11.44
$14.30
$17.16
$20.02
$22.88
$25.74
$28.60
65 - 69
$1.009
$5.05
$10.09
$15.14
$20.18
$25.23
$30.27
$35.32
$40.36
$45.41
$50.45
70 - 74
$1.615
$8.08
$16.15
$24.23
$32.30
$40.38
$48.45
$56.53
$64.60
$72.68
$80.75
75+
See Plan Administrator for premiums.
Dependent Children Monthly Rate = $0.60 per $5,000 and $1.20 per $10,000
Premium covers all dependent children regardless of the number of children.
40
Definitions
Accelerated Death Benefit
Accelerated Death Benefit provides an option to withdraw a percentage of your life
insurance when diagnosed as terminally ill (as defined in the policy). The death
benefit will be reduced by the amount withdrawn. To qualify, you have satisfied
the Active Work rule and have been covered under this policy for the required
amount of time as defined by the policy. Check with your tax advisor or attorney
before exercising this option.
Conversion
If you terminate your employment or become ineligible for this coverage, you have
the option to convert all or part of the amount of coverage in force to an individual
life policy on the date of termination without Evidence of Insurability. Conversion
election must be made within 31 days of your date of termination.
Guarantee Issue
For timely entrants enrolled within 31 days of becoming eligible, the Guarantee
Issue amount is available without any Evidence of Insurability requirement.
Evidence of Insurability will be required for any amounts above this, for late
enrollees or increase in insurance, and it will be provided at your own expense.
Limited Activity
A period when a spouse or dependent is confined in a health care facility; or,
whether confined or not, is unable to perform the regular and usual activities of a
healthy person of the same age and sex.
Portability
If coverage has been in force for at least 12 months, you may continue coverage
for a specified period of time after your employment by paying the required
premium. Portability is available if you cease employment for a reason other than
total disability. A written application must be made within 31 days of your
termination.
Term Life
Coverage provided to the designated beneficiary upon the death of the insured.
Coverage is provided for the time period that you are eligible and premium is paid.
There is no cash value associated with this product.
Exclusion: Suicide
Benefits will not be paid if the death results from suicide within 2 years after
coverage is effective. May apply if employee contributes toward the premium.
Additional Benefits
BeneficiaryConnectSM
Support services for beneficiaries who have experienced a loss.
TravelConnectSM
Travel assistance services for employees and eligible dependents traveling more
than 100 miles from home.
For assistance or additional information
Contact Lincoln Financial Group at (800) 423-2765 or log on to www.LincolnFinancial.com
NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does
not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the
benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.
©2008 Lincoln National Corporation
Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business
in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial
Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its
affiliates. Each affiliate is solely responsible for its own financial and contractual obligations.
ROADURBI
HRST
HRA1D656NA20130304
1.00
41
2013/03/04
Accidental Death & Dismemberment Life
Insurance
Lincoln Financial 800-423-2765 www.lincolnfinancial.com
Build your benefit with Lincoln Financial's Voluntary AD&D Insurance. Accidental Death &
Dismemberment is Life Insurance that is payable if a death is ruled an accident. This policy
also pays benefits for dismemberment of a limb, etc. You have the opportunity to buy valuable
life insurance coverage for yourself or your family – all at affordable group rates.
Employee Only
Insurance Schedules
1 to 10 Times
Salary
Maximum Benefit
Employee Contribution
Rate per $1,000
$500,000
100%
$.024
Family Coverage
50% for spouse w/no
children
40% for spouse w/children.
10% for children
$500,000
100%
$.033
Benefit Amount / $1,000 x Rate per $1,000 = Monthly Premium
Benefit Amount
$10,000
$50,000
$100,000
$150,000
$200,000
$250,000
Examples:
Premium for Employee Only
Coverage
$ 0.24
$ 1.20
$ 2.40
$ 3.60
$ 4.80
$ 6.00
42
Premium for Family
Coverage
$ 0.33
$ 1.65
$ 3.30
$ 4.95
$ 6.60
$ 8.25
Voluntary Accidental Death and Dismemberment Insurance
AD&D
SUMMARY OF BENEFITS
Sponsored by:
Effective date:
September 1, 2013
Benefit
Employee Only Plan
Family Plan
Amount
1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 times annual salary,
rounded to the next higher $1,000.
Spouse: 50% of the employee
benefit, not to exceed $250,000
(Spouse and employee covered)
Each Child: 15% of employee benefit,
not to exceed $30,000 (Children and
employee covered)
Spouse + Each Child: Spouse 40%
and Child 10% of the employee
benefit, not to exceed $30,000
(Spouse, children and employee
covered)
Minimum Amount
$10,000
$5,000
Maximum Amount
$500,000
$250,000
Benefit Reduction
Employee
Spouse
Benefits will reduce:
Benefits terminate at retirement.
Benefits will terminate at employee
retirement.
Additional Benefits
Safe Driver
Education
Spouse Training
Felonious Assault
Alternate
Child Care
Coma
Common Disaster
Exposure
Disappearance
Common Carrier
Eligibility
Employee
Spouse and Dependents
All full-time employees working 20 or more hours
per week in an eligible class are eligible for
coverage on the policy effective date. A delayed
effective date will apply if the employee is not
actively at work.
Cannot be in a period of limited
activity on the day coverage takes
effect.
43
www.LincolnFinancial.com
GLM-07018 Rev. 4/11 Stand Alone VADD
Employee Monthly Premium
Accidental Death and Dismemberment premium for sample benefit amounts
AGE
Monthly
Rate per $25,000
$1,000
< 99
0.024
$50,000
$0.60
$1.20
$75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000
$1.80
$2.40
$3.00
$3.60
$4.20
$4.80
$5.40
$6.00
This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency.
Example: Use this formula to calculate premium for benefit amounts over $250,000.
Example:
Age
Monthly Rate Per $1,000
X
Benefit In $1,000’s
=
Monthly Cost
35
0.024
X
300
=
$7.20
X
=
Family Monthly Premium
Accidental Death and Dismemberment premium for sample benefit amounts
AGE
Monthly
Rate per $25,000
$1,000
<99
0.033
$50,000
$0.83
$1.65
$75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000
$2.48
$3.30
$4.13
$4.95
$5.78
$6.60
$7.43
$8.25
This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency.
Example: Use this formula to calculate premium for benefit amounts over $250,000.
Example:
Age
Monthly Rate Per $1,000
X
Benefit In $1,000’s
=
Monthly Cost
35
0.033
X
300
=
$9.90
X
=
Definitions
AD&D
Accidental Death and Dismemberment (AD&D) insurance provides specified benefits
for a covered accidental bodily injury that directly causes dismemberment (e.g., the
loss of a hand, foot, or eye). In the event that death occurs from a covered accident,
both the life and the AD&D benefit would be payable. This insurance is optional and
can be purchased by you and your spouse.
Limited Activity
A period when a spouse or dependent is confined in a health care facility; or,
whether confined or not, is unable to perform the regular and usual activities of a
healthy person of the same age and sex.
Exclusion: Suicide
Benefits will not be paid if the death results from suicide within 2 years after
coverage is effective. May apply if employee contributes toward the premium.
Additional Benefits
BeneficiaryConnectSM
Support services for beneficiaries who have experienced a loss.
TravelConnectSM
Travel assistance services for employees and eligible dependents traveling more
than 100 miles from home.
44
www.LincolnFinancial.com
GLM-07018 Rev. 4/11 Stand Alone VADD
PrePaid Legal Services
LegalEase www.legaleaseplan.com/content/heb
Enrollment Questions: 800-248-9000
Member Services: 888-416-4313
LegalGUARD® can ease one of the biggest stresses – finding the right
lawyer.
LegalEASE offers employees a customized legal assistance plan called
LegalGUARD. It’s a plan that provides support and protection from
unexpected personal legal issues.
•
•
•
•
•
•
•
•
•
•
•
What employees get with a LegalGUARD Plan:
An attorney with expertise specific to your personal legal matter
Access to a national network of attorneys with exceptional experience that are matched to meet
your needs.
Coverage for in- and out-of-network
Flexible benefit levels, permitting you to use your own attorney
Concierge help navigating common individual or family legal issues
Up to 10 hours of financial counseling per year
The value of a LegalGUARD Plan.
Being a LegalGUARD member saves you time and costly legal fees. But most importantly, it gives
you confidence and provides coverage for:
Home & Residential: Purchase, Sale, Refinancing, Tenant disputes
Financial & Consumer: Consume dispute, Document preparation, Debts
Estate Planning & Wills: Will/codicil, Living trust document, Health Care Power of Attorney
Auto & Traffic: Traffic defense, Administrative proceedings, Misdemeanor defense*
Family: Name change, Divorce*, Adoptions*, Guardianship/Conservatorship*
* Limitations apply
Plan Cost:
The LegalGUARD Plan is only $16.91 per month, via payroll deduction.
The LegalGUARD Plan + Family Coverage is only $18.88 per month, via payroll deduction.
We’re here for you.
To learn more about LegalGUARD and the benefits you receive:
Call: 1(800) 248-9000
Visit: https://www.legaleaseplan.com/content/heb
Limitations and exclusions apply. This benefit summary is intended only to highlight benefits and should not be relied upon to fully
determine coverage. More complete descriptions of benefits and the terms under which they are provided are received upon
enrolling in the plan. Group legal plans are administered by LegalEASE or The LegalEASE Group, Houston, Texas.
Product available in all states. Underwritten by Virginia Surety Company, Inc. Please contact LegalEASE for complete details.
© 2015 The LegalEASE Group. All rights reserved.
45
Why do you need legal coverage?
Never have to worry if it’s worth calling an attorney again.
You never know when a legal matter may affect you or your family, and there are times in life when it is a
good idea to consult an attorney. Legal issues are complicated and disorienting. As many as 7 out of 10 of
people you know will have the need for an attorney this year, according to the American Bar Association.
This means that each year, only 30% of us will be lucky enough not to deal with the stress of a legal issue.
And without the right help, legal matters are tough. Without legal benefits, issues can average anywhere
from $500.00 to $7,000.00 per issue. The LegalGUARD Plan helps protect you, your family and your
savings from unexpected legal costs for many issues.
We understand that when you have a legal need, it is the most important event in your life at that moment.
We also know that finding the right attorney on your own can be stressful and dominate much of your time
and attention. Protect yourself and your family with the great value of the LegalGUARD Plan.
We have been putting people in touch with quality local attorneys and helping them solve problems since
1971. Our processes are designed to help you save time and to make things less stressful. Also, the
providers in our network must meet the most rigorous credentials standards in the market today.
How does the plan work?
The right help when you need it the most.
Finding the right type of attorney when a need arises can be one of the more stressful tasks when dealing
with a legal matter. The right help is essential. There are many types of attorneys depending upon what
type of issue someone may be facing. We help with this first step. We use our experience and relationships
with our network providers to match you to the right type of attorney you need in the right location, with
availability to set up a consultation with you. We see this step as a way to save you time, so you can get
back to your busy schedule of work, kids or whatever may be just as important. This step alone can save
you hours. If you use an In Network attorney, you don’t have to hassle with forms. LegalEASE works
directly with the provider to provide your benefits.
We also always follow up to ensure everything is going well and to see how else we can be of assistance.
We believe that quality service is essential, especially in a world today where quality service can be scarce.
So if you have a legal, financial, or identity need, to start getting the help you need, just give us a call. It’s
that easy. We will guide you through the steps and be right with you the entire way.
46
LegalGUARD Plan Benefits
Benefits are designed to meet the typical needs of an employee and their family. There are no deductibles to
worry about for covered services. Benefits cover the attorney’s time. Other costs, such as filing fees, are not
covered by legal benefits. Listed below are the types of matters that are covered by the new LegalGUARD Plan.
The LegalGUARD plan offers convenience of In Network and Out of Network benefits. Many of the below areas
are fully covered, unless noted.
Consultation
Home
Office Consultation*
Telephone Advice
Purchase of Primary Residence
Sale of Primary Residence
Refinancing of Primary Residence
Landlord/Tenant Dispute*
Consumer
Consumer Dispute
Small Claims Court Representation*
Document Preparation:
Simple Deed
Promissory Note
Consumer Dispute Correspondence
Installment Sales Agreement
Simple Affidavit
General Power of Attorney
Lease Agreement – Tenant Only
Time Share Agreement
Civil
Civil Litigation Defense*
Family
Uncontested Separation*
Consent/default Divorce*
Uncontested Divorce*
Contested Divorce*
Name Change
Guardianship/Conservatorship*
Governmental Agency Adoptions*
Stepparent Adoptions*
Juvenile Court Proceedings
Estate Planning and Wills
Simple Will or Codicil*
Living Will
Health Care Power of Attorney
Living Trust Document
Probate of Small Estate*
Criminal
Traffic Defense (resulting in suspension or
revocation of license)
Administrative Proceeding (regarding suspension or
revocation of license)
Misdemeanor Defense*
Financial
Debt Collection Defense
Pre-litigation defense activities
Trial defense*
Bankruptcy (chapter 7 or 13)*
Tax Audit*
Foreclosure*
Financial Planning*
Savings Coaching*
Budgeting Coaching*
Credit Coaching*
Savings Coaching*
Debt Management Programs*
Elder/Parents
Consultation
Review Documents*
Standard Wills Prepared*
Codicil*
Amendment to a single document*
Amendment(s) to spousal document*
Living Will*
Powers of Attorney*
*Some limitations apply
Enrollment Questions Call:
1(800) 248-9000
More Information at:
https://www.legaleaseplan.com/content/heb
47
Meet LegalEASEsm
We believe people deserve to have a sense of safety and
security, a peace of mind, when it comes to being protected
in legal matters. How we do it is by providing an in-depth
pool of resources to accommodate your legal needs. The
LegalGUARD plan is underwritten by Virginia Surety
Company, Inc.
LegalEASE Corporate Headquarters
5850 San Felipe, Suite 600
Houston, Texas 77057
Member Services: 1(888) 416-4313
We’re here when you need us.
Enrollment Questions Call:
1(800) 248-9000
More Information at:
https://www.legaleaseplan.com/content/heb
Plan Proudly
Offered to
HEB ISD Employees
Plan Cost:
The LegalGUARD Plan is only $16.91 per month, via payroll deduction.
The LegalGUARD Plan + Family Coverage is only $18.88 per month, via payroll deduction.
LegalGUARD Covered Family Member Definition:
The Member’s lawful spouse and children. Eligible Family Members are the Member’s spouse and Member’s
unmarried dependent children, including stepchild, legally adopted child, child placed in the home for adoption
and foster child, up to age 19, and from age 19 up to 26 years if they are enrolled in an accredited school or
college as full-time student(s) and are primarily dependent upon the Member for support.
Limitations and Exclusions Apply.
This benefit summary is intended only to highlight benefits and should not be relied upon to fully determine
coverage. More complete descriptions of benefits and the terms under which they are provided are received
upon enrolling in the plan. Group legal plans are administered by LegalEASE or The LegalEASE Group,
Houston, Texas.
Product available in all states. Underwritten by Virginia Surety Company, Inc. Please contact LegalEASE for
complete details.
© 2015 The LegalEASE Group. All rights reserved.
HurstEulessBedfordIndependentSchoolDistrict_2015
48
Health Savings Accounts (HSA)
HSA Bank 800-357-6246
www.hsabank.com
What is a Health Savings Account (HSA)?
An HSA, or health savings account, is a unique tax-advantaged account that you can use to pay for
current or future healthcare expenses. With an HSA, you’ll have:
• A tax-advantaged savings account that you use to pay for eligible medical expenses as well as
deductibles, co-insurance, prescriptions, vision and dental care.
• Unused funds that will roll over year to year. There’s no “use or lose it” penalty.
• Potential to build more savings through investing. You can choose from a variety of HSA selfdirected investment options with no minimum balance required.
• Additional retirement savings. After age 65, funds can be withdrawn for any purpose without
penalty.
• Money in your account is accessible as it is contributed. You do not have access upfront to all
of the money you are supposed to contribute to the account for the entire year like a Flexible
Spending Account.
Eligibility
•
•
•
•
•
•
To be eligible for a Health Savings Account, you must be covered by a HSA-qualified High
Deductible Health Plan (HDHP). The plan that qualifies as a HDHP is TRS Active Care
Plan 1HD.
You cannot be enrolled in the GAP Plan
You cannot be enrolled in Medicare
You cannot be covered by other health insurance that is not an HDHP
You cannot be considered a dependent on someone else’s tax return
You cannot have a Flexible Spending Account
Maximum Contribution per Year
Individual
Family
Under 55
$3,350
$6,650
Age 55+
$4,350
$7,650
Eligible Medical Expenses
You can use your HSA to pay for a wide range of eligible medical expenses for yourself, your spouse or
tax dependents. HSA funds can be used to reimburse yourself for past medical expenses if the expense
was incurred after your HSA was established. While you do not need to submit any receipts to HSA
Bank, it is a good idea to save your bills and receipts for tax purposes.
An eligible medical expense is an expense that pays for healthcare services, equipment or medications
as described in IRS Publication 502*. In general your HSA can be used for:
o Expenses applied to your health plan deductible
o Dental care services
o Vision care services
o Prescription drugs and medicines
o Certain medical equipment
49
HSA Bank
Welcomes You!
Your employer has presented you with a
great opportunity by offering you a Health
Savings Account (HSA) through HSA Bank.
We’d like to introduce ourselves and show
you why HSA Bank is a trusted financial
healthcare partner.
What is an HSA?
HSAs work together with HSA-compatible health plans. The health plan is used to cover serious illness or injury, while the HSA is used
for current or future expenses that are not paid by the health plan. Try our online calculating tools located at
www.hsabank.com/calculators, to learn more about HSAs and if one is right for you.
What are the advantages of an HSA?
• Funds Roll Over Annually
There is no “use it or lose it” philosophy. If you don’t use it, save it for next year. Or better yet, for retirement.
• Tax Advantages*
Contributions can be made pre-tax or post-tax, distributions for eligible expenses are tax-free and earnings grow
tax-deferred.
• You Own the Account
Even if your HSA-compatible coverage ends, you can still use your HSA funds tax-free for eligible medical expenses.
• Long-term Investment Opportunities**
We offer two investment platforms (www.hsabank.com/investments) that give you a wide variety of stocks, bonds and
mutual funds to choose from.
• You’re in Charge
You choose when to use your HSA or pay out-of-pocket.
HSA Bank is here for you.
HSA Bank is here for you even before you sign up with us. Our Client Assistance Center representatives are HSA experts and will help
show you the way to a healthy future. They provide live assistance Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. – 1 p.m., CT,
at 800-357-6246 and are available via email at askus@hsabank.com. Once enrolled, you’ll receive 24/7 access to your account balance
and transaction history with our toll-free automated Bankline system, (800) 565-3515. You can also set up online access at
www.hsabank.com/member and perform all of your regular banking tasks just by logging in. We’ll help you manage your account by
keeping you up-to-date with emails and other alerts. Plus, we’ll provide you with the tax forms and instructions you’ll need for your
HSA-related tax filing.
*HSA Bank does not provide tax advice. Consult your tax professional for tax-related questions.
** Investment accounts are not FDIC insured and they are not bank guaranteed. Investment accounts are not a deposit account, or an obligation of HSA Bank, and they
may lose value. They are not guaranteed by any federal government agency.
For assistance, please contact the Client Assistance Center
800-357-6246
Monday – Friday, 7 a.m. – 9 p.m., and Saturday 9 a.m. - 1:00 p.m., CT
www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081
50
How to use your HSA
It’s easy to manage your Health Savings Account (HSA) online.
Access real-time account balances, transaction history and statements, as well as track your expenses online. Sign up for online
banking today.
Mobile App – Use your iOS (iPhone, iPod Touch, iPad) or Android-powered device to check available balances in your account and
view HSA transaction details, save and store receipts using your device’s camera, receive account balances and configurable
alerts via text message on any mobile device, and access customer service contact information.
myHealth Portfolio – Use this tool to track your healthcare expenses, submit and retain receipts and claims from multiple
insurance and financial account providers. Also view expenses by provider, category, and more.
How to deposit funds into your HSA.
To maximize HSA tax and savings benefits, begin funding your account as soon as you can. HSA Bank offers several convenient
methods for making contributions to your HSA.
Payroll Deductions – If your employer offers this option, HSA Bank will facilitate recurring pre-tax payroll deductions. Contact
your employer to complete the appropriate paperwork.
Online Transfers – On HSA Bank’s member website, you can transfer funds from an external bank account, such as a personal
checking or savings account, to your HSA.
Check – Mail your personal check and completed Contribution Form to:
HSA Bank, PO Box 939, Sheboygan, WI 53082
How to pay for healthcare expenses from your HSA.
Whether you want to reimburse yourself for an expense paid out-of-pocket or you want to pay directly from your HSA,
HSA Bank offers multiple options for accessing your funds.
Health Benefits Debit Card – Your HSA Bank debit card from Visa® provides access to your HSA funds at point-of-sale with
signature or PIN and at ATMs for withdrawals. Transaction fees may apply when used with a PIN*.
Checks – A book of 50 checks can be ordered upon request for an additional fee*. You can use these checks to pay providers or
reimburse yourself for expenses already incurred.
Online Transfers – On HSA Bank’s member website, you can reimburse yourself for out-of-pocket expenses by making a one-time
or reoccurring online transfer from your HSA to your personal checking or savings account.
Online Bill Pay – Use this feature to pay medical providers directly from your HSA.
*For applicable fees, see your HSA Bank Interest and Fee Schedule.
HSA Bank’s Health Benefits Debit Card can be used for point-of-sale transactions in two ways, signature or PIN. For signature, swipe
card, press credit on the keypad, and sign the receipt. To pay using a PIN (fee per PIN transaction may apply*), swipe your card,
select debit on the keypad, and enter your PIN. To withdraw HSA funds from an ATM (fee per ATM withdrawal may apply*), be sure
to select the “checking” option (not savings) when asked the type of account you are withdrawing from. HSA Bank limits pointof-sale debit card transactions to medical merchants. As a mechanism for fraud protection, HSA Bank has set limits on debit card
transactions. You can withdraw $2,000 per day when a signature is used and $300 per day for PIN-based transactions. Debit card
transactions are also limited to your current daily balance. You are able to make five debit card transactions per day. Any additional
transactions will be denied.
For assistance, please contact the Client Assistance Center:
800-357-6246
Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT
www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081
51
Flexible Spending Account
TASC 800-422-4661
www.tasconline.com
Maximum Contribution
$2,400 per year or $200 per month
52
53
HSA/FSA Comparison Chart
Questions
Who qualifies as a participant?
Health Savings Account
(HSA)
All individuals under 65 who are
participants in a qualified High
Deductible Health Plan (HDHP).
A HDHP is TRS ActiveCare plan 1HD
Flexible Spending
Account (FSA)
All employees (not required to be
on District insurance to
participate)
Non-Medicare enrolled persons
What is the maximum
contribution per year?
Individual - $3,350; over 55 - $4,350
Family - $6,650; over 55 - $7,650
$2,400
Can I access the entire account at No, money is available as it is
contributed to the account
the start of the plan year?
Yes, the total amount elected for
the year is available to the
employee on day one
Employee tax savings?
Contributions are tax-free
Contributions are tax-free
Does interest accrue on the
account?
Interest can be accrued
Interest is NOT accrued
Can I roll unused dollars to next
year?
Yes. Funds may be carried over
indefinitely throughout an account
holder’s lifetime. Upon death, an
account may be passed on to a
surviving spouse.
No
What are qualified medical
expenses on the plan?
Deductibles, coinsurance,
prescriptions, includes dental and
vision
Deductibles, coinsurance,
prescriptions, includes dental and
vision
Are claims substantiated?
Only upon audit
Yes. Receipts may be required.
Can I use the money on nonmedical qualified expenses?
Yes. The expense is subject to taxes
and 10% tax penalty. (After age 65,
no 10% penalty)
No
Is there a “catch up” provision?
Yes, individuals 55 and older may
make additional contributions up to
$1,000 per year.
No
Portability
Yes. It is owned by the account
holder
No
Subject to Cobra?
No
Yes
• 800-422-4661 •
Fax: 608-245-3623
54
Dependent Care Flexible Spending Account
TASC 800-422-4661
www.tasconline.com
Dependent Care
Qualifications
FSA eligibility criteria for Dependent Care expenses
A) The dependent care expenses must be work related. The care must be necessary for the employee and
the employee’s spouse to work, to look for work, or to attend school full-time, or if they are physically
unable to care for their children.
B) The dependent care expenses provided during a calendar year cannot exceed $5,000. In the case of a
separate return by a married individual, the limit is $2,500. This amount may be less if the employee’s
earned income or spouse’s earned income is less than $5,000.
The dependent care expenses must be for the care of one or more qualifying persons. A
qualifying person is one of the following:
A) A dependent who was under age 13 when the care was provided and for whom an exemption can be
claimed.
B) A spouse who was physically or mentally not able to care for himself or herself, and lived with you for more
than half the year.
C) A dependent who was physically or mentally not able to care for himself or herself and for whom an
exemption can be claimed, and lived with you for more than half the year.
To receive the dependent care benefit, one must follow these procedures:
A) All persons and organizations that provide dependent care for a qualified person must be identified. This
information is requested on Form 2441. The name, address, and taxpayer identification number of the
provider must be included. Under certain circumstances, the taxpayer identification number will be a social
security number.
B) If the care is being provided by a center that cares for more than six persons, the center must comply with
all state and local regulations.
C) Payments made to relatives who are not dependents can be included. However, do not include amounts paid
to a dependent for whom you can claim an exemption or for your child who is under age 19 at the end of the
year, regardless of whether he or she is your dependent.
D) Use Form W-10 to request the required information from the care provider.
TASC • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623 • www.tasconline.com
55
Special rules apply to children of divorced or separated parents:
Even if you cannot claim your child as a dependent, he or she is treated as your qualifying person if all of
the following are true:
•
•
The child was under age 13 or was not physically or mentally able to care for himself or herself.
One or both parents provided more than half of the child’s support for the year and are divorced,
legally separated, or lived apart at all times during the last 6 months of the calendar year.
One or both parents had custody of the child for more than half of the year.
• You were the child’s custodial parent. The custodial parent is the parent having custody for the
greater portion of the calendar year. If the child was with both parents for an equal number of
nights the parent with the higher adjusted gross income is the custodial parent.
A non-custodial parent that is entitled to claim the child as a dependent on their tax return may not treat
the child as a qualifying individual for the dependent care benefit even when that parent is financially
responsible for providing the care. Only one parent (the custodial parent) may qualify for the dependent
care benefit for a taxable year. The regulations do not provide any relief for a non-custodial parent that
incurs dependent care expenses for the portion of the year in which they have custody of the child to
enable the non-custodial parent to work.
•
Eligible and Ineligible Expenses for FSA Dependent Care (partial list):
Eligible Expenses (must be employment related)
•
•
•
•
•
•
FICA/FUTA taxes of dependent care provider
Nanny expenses attributed to dependent care
Nursery school (preschool)
Late pick up fees
Day Camp – primary purpose must be custodial care and not educational in nature
Day care when one parent is working and the other is sleeping during daytime hours
Ineligible Expenses
•
•
•
•
•
•
Kindergarten
Activity fees/supplies
Late payment charges
Overnight camp
Transportation
Fees paid to a provider not reporting the income to the IRS
For more information regarding dependent care expenses, please review IRS Publication 503.
56
Retirement Planning
Enrollm ent in a 403(b) and/ or 457 m ay be done anytim e during the year!!
403(b) Plan
457 Plan
The Omni Group
877-544-6664
www.omni403b.com
RAMS / JEM
800-943-9179
www.region10rams.org
What is a 403(b)?
A 403(b) plan is a retirement savings plan
available for public education organizations.
It has tax treatment similar to a 401(k)
plan. Employee salary deferrals into a
403(b) plan are made before income tax is
paid an allowed to grow tax-deferred until
the money is taxed as income when
withdrawn from the plan. 403(b) plans are
also referred to as tax-sheltered annuity.
What is a 457?
The 457 plan is a type of deferredcompensation retirement plan that is
available for governmental employers. The
employer provides the plan and the
employee defers compensation into it on a
pre-tax basis. For the most part the plan
operates similarly to a 401(k) or 403(b)
plan. The key difference is that there is no
penalty for withdrawal before the age of
59½ (but subject to income tax).
You have 20 + companies to choose from
with a variety of investment options
available – Please visit www.trs.state.tx.us
and select 403b Certification and click on
View 403(b) Products List to see the list of fees
charged by each company/product.
HEB ISD has selected 1 company to provide
our employees with the 457b plan.
RAMS/JEM offers several investment
options
How to Enroll:
Step 1: Set up your 403b account with an
approved vendor (see the link
above)
Step 2: Complete the Salary Reduction
Agreement with The Omni Group
(see the following pages for login
instructions)
How to Enroll:
Complete the Salary Reduction Agreement
with RAMS / JEM (see the following pages
for login instructions)
There is a 10% tax penalty on any funds
withdrawn prior to retirement age
No penalty for early withdrawal (upon
separation of service)
Maximum Contributions for 2015:
Annual Maximum - $18,000
Over age 50 Catch-up - $6,000
Maximum Contributions for 2015:
Annual Maximum - $18,000
Over age 50 Catch-up - $6,000
57
58
457(b) Retirement Savings Plan
The 457(b) Retirement Savings Plan is a voluntary savings program designed to allow employees to defer a portion
of their compensation through payroll deductions. These deferrals are made on a pre-tax basis and allow employees the
opportunity to save for retirement. Roth accounts are also available, at the option of the District. The 457(b) Retirement
Savings Plan is an attractive alternative to traditional 403(b) “tax sheltered annuity” programs.
The Retirement Savings Plan is set up under Section 457(b) of the Internal Revenue Code. The plan is offered through
the ESC Region 10 457 Cooperative and Master Plan by means of an interlocal agreement with each participating
District. The Plan works for the most part like a 401(k) plan.
 Employees can enroll in the plan online or with forms without the need to meet with a sales person.
 Educational meetings are offered to the District by salaried representatives of the companies providing the plan
services. No commissions are paid to any individuals or companies from the plan.
A 457(b) plan has the same basic features and advantages of 403(b) and 401(k) plans. However, funds paid out of a
457(b) plan are not subject to an early withdrawal excise tax (unlike 403(b), IRAs or 401(k) plans). Listed below are some
of the additional advantages and features of the Region 10 RAMS 457(b) plan:
1. Protection from Fiduciary Liability. The District, as a plan sponsor, is a fiduciary with a 457 plan and is responsible
for the types of investments offered to participants. Most 457 plans do not protect the District from fiduciary liability. The
ESC Region 10 457 Cooperative and Master Plan offers fiduciary protection for the District through oversight by Region 10
and the IAC and an Investment Advisory Agreement with TCG Advisors, LP whereby TCG agrees to accept fiduciary
responsibility for its investment recommendations.
2. Contribution Limits:
· Allowable contribution amount is the lesser of $18,000 per year or 100% of compensation in 2015.
· Individuals over age 50 can contribute an additional $6,000 in 2015.
· Additional “Catch Up” limits are available.
· Contribution limits are independent of other plan limits such as 403(b) contribution amounts.
(This means that the employee can contribute the maximum amounts to both a 403(b) plan and a 457(b) plan.)
3. Distributions: Distributions are available upon termination of employment, death, retirement or certain types of
hardships. Distributions can be:
· Rolled to an IRA, 403(b) 401(k) or another 457(b) plan that accepts rollovers,
· Used to buy TRS service, or
· Taken as a cash distribution (subject to applicable federal and state income tax).
4. Investments: Investments are managed by TCG Advisors, LP and the ESC Region 10 Investment Advisory Committee
(IAC). Only low cost, high quality, no-load or load-waived mutual funds are used. Participants can choose from 6 risk
based model portfolios (from Capital Preservation to Aggressive Growth), create their own portfolio from the mutual funds
used in the portfolios or invest in a Stable Value Fund designed to provide a competitive interest rate with minimal market
risk. Of course, all investing involves risk.
5. Penalties: There is no 10% excise tax on distributions – not true of 403(b), IRA or 401(k) plans. In addition, the
plan being offered by the District has no surrender charges, withdrawal penalties or other restrictions/penalties.
6. Loans: Participants can obtain loans against their account balances. The interest rate charged is the current lowest
regional rate for collateralized loans. All repayments and interest are credited back to the participant’s account in full.
7. Taxation: Distributions are taxed as income at the time the funds are received as cash. Taxation of principal and
interest can be deferred until the participant reaches age 70 ½, at which time the individual must begin receiving minimum
required distributions as defined by IRS regulations.
8. Company Administering Plan: The company chosen to provide the 457 (b) Retirement Savings Plan is JEM Resource
Partners, a company with many years of proven expertise in administering retirement plans to public sector employees.
JEM and TCG Advisors, LP are affiliated companies
Administered by
900 S. Capital of Texas Highway, Suite 350 - Austin, TX 78746 - Toll Free: (800) 943-9179
Region 10 RAMS website: www.region10rams.org
59
Hurst-Euless-Bedford
ISD
Summary Plan Description
Plan Type
Internal Revenue Code
Section 457(b)
Plan Administrator
JEM Resource Partners
Excluded Employees
Independent Contractors
Plan Password for Enrolling Online
hurst457
Plan Effective Date
05/01/2014
Plan Year End
8/31
Contribution Tax Treatment
Pre-Tax
Contribution Sources
Employee Only
Catch-Up Contribution Limit
Available for employees age 50+
Rollovers Into Plan
Available from another qualified plan
Rollovers Out of Plan
Available to another qualified plan,
upon termination of service
Distributions
Available for the following:
- Separation of Service
- Death
- Disability
Unforeseeable Emergency
Distributions
Available as defined by the IRS for
this type of plan
Loans
Available, see the Loan Agreement
and Application Form
Beneficiaries
A Designation of Beneficiary Form
is only required if Spouse is not the
Primary Beneficiary
Fees of Service Plan Providers
JEM Resource Partners, TPA
$18.50 per participant per year
0.25% of assets, paid by the
participant
Wilmington Capital Trust,
Custodian/Trustee
0.10%, paid by participant
Inactivity Distributions
Available for accounts with
balances of less than
$5,000, and no activity for 2
years
TCG Advisors, Investment Advisor
Other Fees
Sliding Scale (0.45% -0.25%),
currently 0.40%, paid by participant $30 Distribution Fee
$50 Loan Set up
All of the above paid by
ESC Region 10, Plan Coordinator
participant
$0.10 per participant per month,
paid by participant
For more information please contact JEM Resource Partners, the Plan Administrator
This document is designed to inform Participants about the Plan in non-technical language. Every attempt is made to convey the Plan
accurately. If anything in this Summary Plan Description varies from the Plan Documents, Plan Documents govern.
60
457(b) Plan Enrollment Instructions
1. Go to www.region10rams.org to set up your salary deferral (contribution amount) and allocation
a. Click on “Login” at the upper right corner
b. From the navigation bar, select your Employer
c. Select the “457(b)” tab
d. Select “Register”
e. Enter the Plan Password from the Summary Plan Description
f. Enter Social Security Number without dashes
g. Select “Begin”
2. Upon entering the site, you will move through 5 steps:
a. Personal Information
• Enter your personal information and hit “Next”
b. Beneficiaries
• Click “Add Additional Beneficiary”
• Enter in the Beneficiary information and click “Next”
c. Contributions
• Select your Action from the drop down box for either the Pretax or Roth
contribution type
• Enter the contribution rate and hit “Next”
Please note that the contribution amount is the amount you want deducted
from your paycheck EVERY pay period
d. Investment Elections
• Select the Source of Money in which to apply the allocation
i. Apply the percentage of your contribution to the investment of your choice
ii. The elections must total 100%
e. Confirmation
• Please confirm that all information is correct, including your Investment Election,
and click “finish”
Congratulations, your Account has been created. Additionally, the contribution amount to be
deducted from your pay check will be communicated with the District. Please call JEM Resource
Partners with any questions or concerns to help you set up your account.
JEM Resource Partners
Toll Free (800)943-9179 | Toll Free Fax (888) 989-9247
61
Notices
Notice to Employees: Requirements of the Affordable Care Act
As of January 1, 2014, the Affordable Care Act (ACA) requires you to have health insurance for yourself and
your dependents. Some people are exempt from this requirement. To learn how to apply for an exemption see Questions
and Answers on the Individual Shared Responsibility Provision, www.irs.gov/uac/Questions-and-Answers-on-theIndividual-Shared-Responsibility-Provision. If you do not have health insurance and you are not exempt, you may be
subject to a penalty (see www.healthcare.gov/what-if-someone-doesnt-have-health-coverage-in-2014). The penalty takes
effect on the first day of the 2014 plan year (September 1, 2014).
Enrollment in TRS-ActiveCare satisfies the requirement to have health insurance. The TRS-ActiveCare
Enrollment Guide explains who is eligible to enroll in ActiveCare.
Enrollment in another plan, such as through a spouse, parent, or association, also satisfies the requirement to have health
insurance if the plan provides minimum essential coverage.
As an alternative to ActiveCare or another health insurance program, you may enroll in insurance through
the Health Insurance Marketplace. In Texas, the Marketplace is a federal government program that will offer “onestop shopping” to find and compare private health insurance options. Most individuals are eligible to enroll in insurance
through the Marketplace. The Marketplace began enrollment in October 2013 for coverage beginning in January 2014. For
information on the Marketplace, see www.healthcare.gov.
You may be eligible for a premium tax credit or other assistance toward insurance obtained through the
Marketplace, depending on your household income. More information on the premium tax credit and other cost
sharing provisions is available at www.healthcare.gov. Please note that the district will not contribute to premium costs if
you enroll in insurance through the Marketplace. Also, you will lose the benefit of paying the premium with pre-tax income
if you purchase insurance through the Marketplace.
Additional information. If you have questions or concerns about the health insurance offered through the district,
please contact: Maria Ortiz 817-399-2056 or mariaortiz@hebisd.edu. Questions about the Marketplace and how the
Affordable Care Act impacts you as an individual should be addressed to www.healthcare.gov or your personal attorney.
Basic Information about Health Care Offered By the District
If you decide to shop for coverage in the Marketplace, below is the employer information you will enter at HealthCare.gov
to find out if you are eligible for a premium tax credit.
This information is numbered to correspond to the Marketplace application.
3. Em ployer nam e
4. Em ployer I dentification N um ber (EI N)
5. Em ployer Address
6. Em ployer phone num ber
1849 Central Drive
7. City
Bedford
75-6004311
(817) 399-2056
8. State
7. Zip Code
Texas
76022
10. W ho can w e contact about em ployee health coverage at this job?
Maria Ortiz
11. P hone num ber (if different from above)
12. Em ail address
(817) 399-2056
mariaortiz@hebisd.edu
The district offers health coverage through TRS-ActiveCare to all eligible employees and their eligible dependents. Eligibility
is described in the ActiveCare Enrollment Guide. The coverage offered by ActiveCare meets the minimum value standard
and the cost of this coverage to you is intended to be affordable.
62
Benefit Enrollment Instructions
You will sign up for all benefits through our
online enrollment system, In-Roll at
www.in-roll.com. We encourage all
employees to make arrangements to either
visit a representative or go online to verify
your personal information and benefit
election.
 Verify all information for yourself and
all dependents.
 Only the dependents listed in In-Roll
will be eligible for benefits.
 Under each benefit section, you must
accept or waive the coverage for
yourself and each dependent listed.
 Always print a confirmation sheet
once you have completed your
enrollment to keep for your records.
CONFIRMATION STATEMENT:
Once you have completed your enrollment,
you will see a “Confirmation Statement”. This
page shows you the benefit selections made,
the cost of these benefits, and dependents
entered into the system. Click the “Print and
Save” button at the bottom of this page to
create a printable version of this document.
Once the printable version appears, click
file/print to print a copy for your records.
Note: If you have a valid email address in the
system, you can also request to have a copy of
your Confirmation Statement emailed to you.
USERNAME AND SECURE PASSWORD:
User Name- Your user name will be the first initial
of the legal first name on record with your
employer, followed by your entire last name,
followed by the last 4 digits of your SS#.
(Ex: employee name- Robert Smith, SS# 123-456789 User Name will be: rsmith6789)
Default Password- Your default password for the
initial log in will be hebisd
If the option to email a statement does not
appear, return to the Verify Information
screen and make sure you have a valid email
address entered in InRoll. After this document
prints, click the Exit link at the top of the page
to close your enrollment site.
-----------------------------------------------------InRoll Online Benefit
Enrollment Assistance:
(866) 631-8777
www.in-roll.com
------------------------------------------------------
All Passwords have been reset to the Default
Password for the open enrollment. Be sure to
change your password to something that is easy to
remember, yet secure, as you will be the only one
with access to it. Once you have successfully
changed your password you will be directed to a
Welcome Page.
WELCOME PAGE:
Please read the information and instructions
included on the Welcome Page, about your benefits
and how to enroll in your benefits.
63

Employee Benefits Guide - Hurst-Euless

Transcription

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