66
Employee Benefit Guide ESC Region 11 Employee Benefits Cooperative EFFECTIVE 09/01/2014 - 08/31/2015 www.region11bc.com
Employee Benefit Guide
ESC Region 11
Employee Benefits Cooperative
EFFECTIVE 09/01/2014 - 08/31/2015
www.region11bc.com
Table of Contents
1 Contact Information
2 Online Benefit Enrollment
3-7 Employee Guide to Enroll in Benefits
8 Rate Chart
9-10 TRS ActiveCare Medical
11-14 NBS Flexible Spending Accounts
Benefit Contact Information Refer to this list when you need to contact one of your benefit providers. For general information please contact your
Benefits Department, Financial Benefit Services or log on to www.region11bc.com.
44-51 American Public Life Cancer
52-55 Loyal American Accident
56-62 Unum Life/AD&D
63-64 ID Watchdog Theft Protection
65 MDLIVE Telehealth
15-20 HSA Bank Health Savings Accounts
21-24 American Public Life MEDlink
25-28 Cigna PPO Dental
39-32 Guardian DHMO Dental
33-34 Block Vision
35-43 UNUM Disability
Program Vendor Phone Number Website/Email
ESC Region 11 BC Benefits Financial Benefit Services (800) 583-6908 http://www.region11bc.com
TRS ActiveCare Aetna (800) 222-9205 http://www.trsactivecareaetna.com
Flexible Spending Accounts National Benefit Services (800) 274-0503 http://www.nbsbenefits.com
Health Savings Accounts HSA Bank (800) 357-6246 http://www.hsabank.com
MEDLink American Public Life (800) 256-8606 http://www.ampublic.com
Group #13060
PPO Dental Cigna (800) 244-6224 http://www.mycigna.com
Group #3336975
DHMO Dental Guardian (800) 541-7846 http://www.guardianlife.com
Group #429340
Vision Block Vision (866) 265-0517 http://www.blockvision.com
Group #320580
Disability Unum (800) 583-6908 http://www.unum.com
Cancer American Public Life (800) 256-8606 http://www.ampublic.com
Group #13060
Accident Loyal American (800) 366-8354 http://www.loyalamerican.com
Life and AD&D Unum (800) 583-6908 http://www.unum.com
Identity Theft Protection ID Watchdog (800) 237-1521 http://www.idwatchdog.com
Telehealth MDLIVE (888) 365-1663 http://www.consultmdlive.com
1
Example)
Example) John Smith 000-00-4321
Username: smithj4321 Password: smith4321
If you have trouble logging in, click on the “Login Help Video” for assistance.
2
George Washington 000-00-1234
Username: washing1234 Password: washington1234
All passwords have been RESET to the default described below:
Username:
The first Six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.
Passwords
Default Password:
Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.
3
Enrollment Instructions
Click on “Enrollment
Instructions” for more
information about how to
enroll .
Online Benefit Enrollment
1
For benefit information and to enroll go to: www.region11bc.com
2
Benefit elections will become effective 9/1/2014. Elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved. After annual enrollment closes, benefit changes can only be made if you experience a qualifying event. Changes must be made within 30 days of event. Medical coverage is now enrolled in THEbenefitsHUB. Aetna is the new provider for TRS ActiveCare. Three plans are available: ActiveCare 1-HD, ActiveCare Select, and ActiveCare 2. ActiveCare 3 is no longer available. If you currently participate in a Health Care or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. ALL PARTIPANTS will receive new cards.
Telehealth benefits are now provided by MDLIVE. Family coverage provides services for all family members. Employees and dependents do not have to enroll in a TRS medical plan to enroll in benefit. The PPO Plan options by Cigna have changed. The High Option PPO coinsurance percentage are now 100% for Type I, 70% for Type II, and 40% for Type III. The Low Option PPO has changed to the MAC Plan. Type III services have been added and participants are encouraged to use in-network dentist, as you can be balance billed for out-of-network services. Heath Savings Accounts offered by participating districts will now be through HSA Bank. If you currently have funds in your account, your may transfer them to HSA Bank by completing the transfer form on the benefits website.
ESC Region 11 Benefits Cooperative Employee Benefits HUB: www.region11bc.com
Benefit Information access / Online Enrollment Access / FBS Contact Information
Don’t Forget!
Benefit Updates - What’s New:
www.region11bc.com
ESC Region 11 BC Enrollment is from
08/01/2014 through 08/31/2014
Annual Benefit Enrollment 9/01/2014 - 8/31/2015
Login and complete your benefit enrollment from 8/1/2014—8/31/2014.
ENROLLMENT ASSISTANCE: Call Financial Benefit Services at 866-914-5202 to speak to a representative. Employees
have access to licensed insurance agents Monday-Friday during the month of August. Bilingual agents are also
available for assistance in Spanish.
Update your profile information: home address, phone numbers, email, etc.
Update dependent social security numbers and student status for college aged children.
3
During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year unless a Section 125 qualifying event occurs.
Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.
Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.
Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
All new hire enrollment elections must be completed in the online enrollment system within the first 30 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.
Where can I find forms? For benefit summaries and claim forms, go to your school district’s benefit website: www.region11bc.com. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section.
How can I find a Network Provider? For benefit summaries and claim forms, go to your school district’s benefit website: www.region11bc.com. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.
When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.
Annual Enrollment
New Hire Enrollment
Q&A
4
Plan Carrier Maximum Age
Medical Aetna 26
Dental PPO Cigna 26
Dental HMO Guardian 25(26 if Full-Time Student)
Vision Block Vision 26
Cancer American Public Life 26
Accident Loyal American 25
Voluntary Life/AD&D Unum 26
ID Theft Protection ID Watchdog 26
MEDLink American Public Life 26
Telehealth MDLIVE 26
Flexible Spending Accounts National Benefit Services 26 (benefits terminate at the end of the plan year following the birthday)
Health Savings Accounts HSA Bank 26 (benefits terminate at the end of the plan year following the birthday)
Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, up to the end of the month in which they reach the maximum age
If your dependent is disabled, coverage can continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.
Dependent Eligibility Requirements
Supplemental Benefits: Eligible employees must work 17.5 or more regularly scheduled hours each work week.
Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2014 benefits become effective on September 1, 2014, you must be actively-at-work on September 1, 2014 to be eligible for your new benefits.
Employee Eligibility Requirements
!
5
Changes In Status Qualifying Events
Marital Status A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
Change in Number of Tax Dependents
A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.
Change in Status of Employment Affecting
Coverage Eligibility
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.
Gain/Loss of Dependents' Eligibility Status
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent status.
Judgment/Decree/Order
If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child ( including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.
Eligibility for Government Programs
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
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 qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event .
Section 125 Cafeteria Plan Guidelines
6
Benefit Summary www.region11bc.com Medical & Dependent Care Accounts by National Benefit Services Tax-sheltered flexible spending accounts allow an individual to set aside pre-tax dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year and contributions are use it or lose it. The medical reimbursement maximum is $2,500/plan year. The dependent care reimbursement maximum is $5,000 if married or $2,500 if single per plan year.
NEW CARRIER! Health Savings Accounts by HSA Bank An HSA is a tax free savings account available to employees enrolled in a high deductible health insurance plan. Deposited funds are tax deductible and are used to pay for medical expenses. The annual contribution maximum for 2014 is $3,300 for individual and $6,550 for family. For individuals who are between the ages of 55 and 65, there is an additional catch-up provision of $1,000 that can be contributed annually. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Current participants must complete a transfer form.
PLAN CHANGES! PPO Dental Insurance by Cigna Two PPO options are available that allow participants the freedom to choose any dentist.
High Option Plan: There are no waiting periods for Type I and Type II services. Coinsurance percentages have changed. Type I services are paid at 100%, Type II services are paid at 70% and Type III services are paid at 40%. Orthodontics covered only for children to age 26, with a $1,000 lifetime maximum.
MAC Plan: This plan covers only Type I and Type II services with no waiting periods. Type I services are paid at 100%, Type II services are paid at 80%. Type III services are paid at 50%. Plan includes a $1,000 annual maximum. No Orthodontia services are covered on this plan. Participants should stay in-network, as they could be balance billed for out-of-network services.
Disability Protection by Unum Plan provides a monthly income to an individual that is disabled due to an accident or illness. There are 2 different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. *All new or increases in coverage are subject to a pre-existing condition exclusion.
This is only an outline of benefits. If the terms of this benefit summary differ from your policy, the policy will govern.
DHMO Dental Insurance by Guardian In-network providers must be used for all services. Office visit co-pay is $5.00. All services are paid per the plan schedule co-pay amount so plan participants always know the out-of-pocket costs. No waiting periods and no lifetime maximums. Employee must choose dentist upon enrollment in the DHMO plan.
Vision Insurance by Block Vision Members pay an in-network exam co-pay of $10.00 and a materials co-pay of $10.00. Exam, lenses and frames (within plan allowances) are covered in-network once every 12 months.
Cancer Insurance by American Public Life Plan allows enrollment on a Guarantee Issue Basis (no health questions asked). However, no benefits are payable during the first year of coverage for a pre-existing condition. Cancer insurance is designed to be a supplement and pays for many costs not covered by your major medical plan.
MEDlink® by American Public Life Benefit is designed to supplement your employer’s medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles and coinsurance of your employer’s medical plan. Plan includes an in-hospital benefit, out-patient benefit, and a physician benefit. This policy has limitations and exclusions.
Accident Insurance by Loyal American Coverage pays benefit amounts for covered medical expenses as a result of an accident. Benefits are paid in addition to what your medical carrier pays and the money comes to you, not your medical provider.
Term Life/AD&D Insurance by UNUM Eligible employees with each school district receive Base Life and AD&D as an employer paid benefits. The Voluntary Term Life is available for the employee, spouse and dependent children. All new hires can enroll on a Guarantee Issue Basis (no health questions asked) for the new plan year. *All new elections or coverage increases above GI are subject to evidence of insurability.
Identity Theft Protection by ID Watchdog ID Watchdog is an identity theft and recuperation service which protects your identity from being stolen. ID Watchdog also helps recuperate any losses should your identity be stolen.
NEW CARRIER! Telehealth by MDLIVE This plan allows employees of participating districts and their household members to call in to a licensed network doctor for non-emergencies such as answers to medical questions and diagnosis for common conditions.
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2014–2015 TRS-ActiveCare Plan Highlights
Type of Service ActiveCare 1-HD ActiveCare Select ActiveCare 2
Deductible (per plan year)
$2,500 employee only$5,000 employee and spouse; employee and child(ren); employee and family
$1,200 individual$3,600 family
$1,000 individual$3,000 family
Out-of-Pocket Maximum (per plan year; does include medical deductible/any medical copays/coinsurance)
$6,350 employee only**$9,200 employee and spouse; employee and child(ren); employee and family**
$6,350 individual$9,200 family
$6,000 per individual$12,000 family
Coinsurance Plan pays (up to allowable amount)Participant pays (after deductible)
80%20%
80%20%
80%20%
Office Visit Copay Participant pays
20% after deductible $30 copay for primary$60 copay for specialist
$30 copay for primary$50 copay for specialist
Preventive CareSee reverse side for a list of services
Plan pays 100% Plan pays 100% Plan pays 100%
High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays
20% after deductible $100 copay plus 20% after deductible $100 copay plus 20% after deductible
Inpatient Hospital (preauthorization required)(facility charges)Participant pays
20% after deductible $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
20% after deductible $150 copay plus 20% after deductible (copay waived if admitted)
$150 copay plus 20% after deductible (copay waived if admitted)
Outpatient SurgeryParticipant pays
20% after deductible $150 copay per visit plus 20% after deductible $150 copay per visit plus 20% after deductible
Prescription Drugs Drug deductible (per plan year)
Subject to plan year deductible $0 for generic drugs$200 per person for brand-name drugs
$0 for generic drugs$200 per person for brand-name drugs
Retail Short-Term (up to a 31-day supply)• Generic copay• Brand copay (preferred list)• Brand copay (non-preferred list)Participant pays
20% after deductible
$20$40***50% coinsurance
$20$40***$65***
Retail Maintenance (after second fill; up to a 31-day supply)• Generic copay• Brand copay (preferred list)• Brand copay (non-preferred list)Participant pays
20% after deductible
$25$50***50% coinsurance
$25$50***$80***
Mail Order and Retail-Plus (up to a 90-day supply)• Generic copay• Brand copay (preferred list)• Brand copay (non-preferred list)Participant pays
20% after deductible
$45$105***50% coinsurance
$45$105***$180***
Specialty DrugsParticipant pays
20% after deductible 20% coinsurance per fill $200 per fill (up to 31-day supply)$450 per fill (32- to 90-day supply)
Monthly Premium CostEmployee onlyEmployee and spouseEmployee and child(ren)Employee and family
$325$850$572$1,145
$450$1,044$709$1,238
$555$1,287$875$1,323
A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician.*Illustrates benefits when network providers are used. For some plans non-network benefits are also available; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which may be considerable.**Includes prescription drug coinsurance***If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.
TRS-ActiveCare 3 to be discontinued effective September 1, 2014
The Teacher Retirement System of Texas (TRS) regularly reviews the TRS-ActiveCare plan options to ensure the plans meet the health care needs of public school employees and their families. Based on this review, TRS will eliminate the ActiveCare 3 option for the 2014-2015 plan year.
Effective September 1, 2014 through August 31, 2015 | Network Level of Benefits*
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TRS-ActiveCare Plans – Preventive Care
Preventive Care Services
Network BenefitsWhen Using Network Providers
(Provider must bill services as “preventive care”)
ActiveCare 1-HD ActiveCare Select ActiveCare 2 Network
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.
Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the HRSA for infants, children, and adolescents; and
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)
After deductible, plan pays 80%; participant pays 20%
$30 copay for primary$60 copay for specialist
$30 copay for primary$50 copay for specialist
Annual Hearing Examination After deductible, plan pays 80%; participant pays 20%
$30 copay for primary$60 copay for specialist
$30 copay for primary$50 copay for specialist
Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. There is no coverage for non-network services under the ActiveCare Select plan.
TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.
2014–2015 TRS-ActiveCare Plan Highlights
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Get Your Money
1. Complete and sign a claim form (available on our website) or an online webclaim.
2. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider.
3. Fax or mail signed form and documentation to NBS.
4. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.
NBS Flexcard—FSA Pre-paid Benefit Card
Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.
How the FSA Plan WorksYou designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited.
However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.
Account InformationParticipants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (888) 353-9125. For immediate access to your account information at any time, log on to our website NBSbenefits.com. Information includes:
• Detailed claim history and processing status• Health Care and Dependent Care account balances• Claim forms, worksheets, etc.• Online Claim Submission
Enrollment Considerations
After the the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds.
NATIONAL BENEFIT SERVICES, LLC8523 South Redwood Road
West Jordan, UT 84088
Phone: 800-274-0503 Fax: 800-478-1528
Email: [email protected]
NBSbenefits.com
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_______________________________________________________________________________________________________
8523 S Redwood Rd, West Jordan, UT 84088 (800) 274-0503 Fax (801) 355-0928 www.NBSbenefits.com
Health Care Expense Account
Sample Expenses
Medical Expenses Dental Expenses Vision Expenses
Acupuncture
Addiction programs
Adoption (medical expenses for baby birth)
Alternative healer fees
Ambulance
Body scans
Breast pumps
Care for mentally handicapped
Chiropractor
Co-payments
Crutches
Diabetes (i.e. insulin, glucose monitor)
Eye patches
Fertility treatment
First aid (i.e. bandages, gauze)
Hearing aids & batteries
Hypnosis (for treatment of illness)
Incontinence products (ie Depends, Serene)
Joint support bandages and hosiery
Lab fees
Monitoring device (blood pressure,
cholesterol)
Physical exams
Pregnancy tests
Prescription drugs
Psychiatrist/Psychologist (for mental
illness)
Physical therapy
Speech therapy
Vaccinations
Vaporizers or humidifiers
Weight loss program fees (if prescribed by
physician)
Wheelchair
Artificial teeth
Co-payments
Deductible
Dental work
Dentures
Orthodontia expenses
Preventative care at dentist office
Bridges, crowns, etc.
Braille – books & magazines
Contact lenses
Contact lens solutions
Eye exams
Eye glasses
Laser surgery
Office fees
Guide dog and its upkeep, other animal aid
Items listed below generally do not qualify for reimbursement
Personal Hygiene (i.e. deodorant, soap, body
powder, shaving cream, sanitary products)
Addiction products
Allergy relief (oral meds, nasal spray)
Antacids and heartburn relief
Anti-itch and hydrocortisone creams
Athlete’s foot treatment
Arthritis pain relieving creams
Cold medicines (i.e. syrups, drops, tablets)
Cosmetic surgery
Cosmetics (i.e. makeup, lipstick, cotton swabs,
cotton balls, baby oil)
Counseling (i.e. marriage/family counseling)
Dental care – routine (i.e. toothpaste,
toothbrushes, dental floss, anti-bacterial
mouthwashes, fluoride rinses, breath strips,
teeth whitening/bleaching, etc.)
Exercise equipment
Fever & pain reducers (i.e. Aspirin, Tylenol)
Hair care (i.e. hair color, shampoo,
conditioner, brushes, hair loss products)
Health club or fitness program fees
Homeopathic supplement or herbs
Household or domestic help
Laser hair removal
Laxatives
Massage therapy
Motion sickness medication
Nutritional and dietary supplements (i.e. bars,
milkshakes, power drinks, Pedialyte)
Skin care (i.e. sun block, moisturizing lotion,
lip balm)
Sleep aids (i.e. oral meds, snoring strips)
Smoking cessation relief (i.e. patches, gum)
Stomach & digestive relief (i.e. Pepto-Bismol,
Imodium)
Tooth and mouth pain relief (Orajel, Anbesol)
Vitamins
Wart removal medication
Weight reduction aids (i.e. Slimfast, appetite
suppressant
These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition)
For Additional Information, Visit www.nbsbenefits.com Welfare-547 (1/12)
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HSA and FSA Plan Availability
Employees of the following districts may participate in either the HSA or
FSA, but not both:
Alvord ISD Muenster ISD
Argyle ISD Palmer ISD
Arlington Classics Academy Palo Pinto ISD
Bonham ISD Poolville ISD
Callisburg ISD Santo ISD
Chico ISD Valley View ISD
East Forth Worth Montessori Van Alstyne ISD
East Grand Preparatory Whitesboro ISD
Lingleville
Employees of the following districts may enroll in both the HSA and FSA
where FSA becomes a limited expense account*:
Era ISD
Evolution Academy
Lindsay ISD
Stephenville ISD
Treetops International
Valley View ISD
*This FSA account Limits funds to dental, vision, and preventative care expenses.
If you have additional questions about the differences between the limited and unlimited
FSA plans, please call (800)583-6908.
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More savings. More choices. More focus on your health.
It’s all possible when you combine the right health plan with a Health Savings Account (HSA).
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It’s easy with HSA Bank.
What is an HDHP? An HDHP, or high-deductible health plan, is a major-medical health insurance plan that has a lower premium than traditional health plans. Your HDHP:
• Is a major-medical health plan that is HSA-compatible. That means it can be used with a health savings account from HSA Bank
• Has a higher annual deductible with lower monthly premiums, which means you’ll have less taken out of your paycheck and more to add to your HSA
• Covers 100% of preventive care, including annual physicals, immunizations, well-woman and well-child exams, and more – all without having to meet your deductible
• Provides coverage for health screenings, such as blood pressure, cholesterol, diabetes, vision, hearing and more
What is an 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 self-directed investment options with no minimum balance required
• Additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty
Start saving more on healthcare. HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses while protecting your health and finances. It combines a high-deductible health plan (HDHP) from your insurance provider with a tax-advantaged health savings account (HSA) from HSA Bank. Together, they offer you health, savings and tax advantages that a traditional health plan can’t duplicate.
Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA.
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How do an HDHP and an HSA work together for you?• While paying lower premiums for your HDHP, you can put those savings into your HSA
• You can use your HSA funds to pay for eligible healthcare expenses until you meet your annual deductible
How can you benefit from tax savings?An HSA provides triple tax savings by reducing your Federal, State* and FICA taxes. Here’s how:
• Contributions to your HSA can be made with pre-tax dollars, which reduces your taxable income
• Any after-tax contributions that you make to your HSA are tax deductible
• HSA funds earn interest tax free and when used for eligible healthcare expenses are also free from tax
* HSA contributions are taxed in AL, CA, NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax-related questions.
You can use the savings to fund your HSA account
Compare and see the HSA Advantage!Annually, this typical family of four will face these medical expenses:
MediCAl exPenses HdHP witH HsA PlAn $4,000 Annual Deductible
trAditionAl PlAn$1,500 Annual Deductible
8 Doctor Visits $568 $200
4 Preventive Care Visits $0 $0
2 Urgent Care Visits $254 $150
1 Outpatient Surgery (Ear Tube Placement) $903 $903
Total Medical Expenses (this is also the annual amount the employee contributes to their HSA)
$1,725 $1,253
Cost CoMPArison
Employee’s Annual Premium $3,076 $4,072
Total Medical Expenses $1,725 $1,253
Federal Tax Savings -$259 $0
Social Security and Medicare (FICA) Tax Savings -$132 $0
State Tax Savings -$69 $0
Out-of-Pocket Expenses $4,341 $5,325
sAvings witH An HdHP/HsA PlAn $984
This comparison is for illustrative purposes only. Medical services charges were obtained from www.healthcarebluebook.com. Employee’s Annual Premium obtained from Kaiser Family Foundation AND Health Research & Educational Trust Employer Health Benefits 2011 Annual Survey. Actual medical costs may vary. Assumes a 15% Federal income tax rate, 7.65% FICA tax rate, 4% State income tax rate. HSA Bank does not provide tax advice. Please consult your tax advisor.
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When it comes to the benefits of opening a Health Savings Account (HSA) with HSA Bank, healthcare savings is just the beginning! After all, we’ve been managing HSAs exclusively since they were introduced. And over the years, we’ve developed a high level of expertise that you can depend on, including:
An exceptional customer service experience: Our priority is helping you understand how to take full advantage of your HSA. Our Client Assistant Center Representatives are dedicated to providing the guidance you need to successfully access, manage, and grow your HSA funds.
Easy contributions and withdrawals: From payroll deductions to scheduled transfers, we make it simple to contribute funds to your HSA. And our HSA Bank Visa® debit card makes it easy to use your HSA to pay for eligible healthcare expenses.
Online account management: Our Internet Banking website gives you fast, easy access to your account 24 hours a day. This means you can conveniently transfer funds, review statements or account balances, access tax documents, and more...whenever you want to.
HSA Bank is a division of Webster Bank, N.A. Webster Financial Corporation (NYSE: WBS) is the holding company for Webster Bank, N.A. Member FDIC. FN50116 1/12
About HSA Bank
How to get started!
Contact your employer for enrollment information or visit www.hsabank.com to learn more.
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Frequently Asked Questions
Health Savings Account (HSA) Medical Reimbursement Flexible Spending Account (FSA)
Description Individual bank account in your name that allows you to save and pay for unreimbursed qualified medical, dental, and vision expenses tax-free.
Individual account through your Employer’s 125 Plan that allows you to pay for qualified medical, dental, and vision expenses tax-free.
What happens to my funds at the end of the year?
Funds contributed never expire and can accumulate year after year.
Funds contributed must be used by the end of the plan year or they are forfeited*. ‘Use it or lose it.’
Do I have to be enrolled in a medical plan?
Yes. Requires enrollment in an IRS qualified high deductible health plan. TRS ActiveCare HD-1 qualifies.
No. You do not have to be enrolled in a medical plan to elect the FSA.
When are funds available? Funds are available for use only as they are contributed per payroll deduction.
Funds for the entire plan year are available for use on September 1, then payroll deducted throughout the year.
Do I get a debit card? Yes Yes What are the 201п annual maximum amounts?
Yearly contribution maximum amount is $3300.00 for an individual, $6550.00 for family. Accountholders age 55+ can contribute an additional $1,000 as a “catch-up.”
Yearly contribution maximum is $2500.00 regardless of individual or family.
Who can I use the funds for? Benefits can be used for any member of the family being claimed on the employee’s tax return.
Benefits are available for any member of the family being claimed on the employee’s tax return.
Can I invest the funds? Funds in the account in excess of $2000.00 are eligible for investing in mutual funds, yielding tax free earnings.
Funds cannot be used for investment purposes.
What happens at retirement? HSA funds can be fully withdrawn at retirement for any purpose, applicable taxes will be due.
Funds are not available for withdrawal at retirement due to the ‘Use it or lose it.’
Are there any fees? $1.75 monthly maintenance fee will apply for balances below $3000.00. Balances over $3000.00 have no monthly maintenance fee.
No monthly maintenance fee.
Do the funds in the account earn interest?
Funds in the account will earn interest ranging from 0.10% to 1.0% depending on the account balance.
Funds in the account do not earn interest.
What if I want to contribute more to the account than what is being payroll deducted?
A monthly payroll deduction is set up to contribute to the HSA. Employees may also send in additional contribution amounts directly to the bank as long as the total annual amount does not exceed the maximum.
A monthly payroll deduction is set up to contribute to the FSA. No contributions outside of payroll deduction are allowed.
What happens when I leave employment?
Funds are portable, rollover year to year, and available between jobs.
If you have a remaining balance in your account, the funds are COBRA eligible and can be used through the end of the current plan year only (August 31).
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Limited Benefit Medical Expense Supplement Insurance MEDlink®
APSB-22295(TX)-0813 MGM/FBS
THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THIS 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 NOTIFICATION THAT MUST BE FILED AND POSTED.
®
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Benefit Description Available OptionsIn-Hospital Benefit Maximum In-Hospital Benefit $1,500 to $2,500 per confinement
Outpatient Benefit up to $200 per treatment
Physician Outpatient Treatment Benefit $25 per treatment; $125 max per family per Calendar Year
In-Hospital Benefit Pays up to the maximum In-Hospital benefit for Covered Charges incurred when a Covered Person is confined in a Hospital as an Inpatient for at least 18 continuous hours.
Other (or Another) Medical Plan means any basic major medical or comprehensive medical policy which includes managed care and through which a Covered Person has coverage. The term Other Medical Plan does not include CHAMPUS.
Outpatient BenefitsPays a benefit for Covered Charges incurred by a Covered Person for treatment in a Hospital emergency room without the Covered Person subsequently being considered an Inpatient; surgery performed in a Hospital outpatient facility or a free-standing outpatient surgery center; or diagnostic testing performed in a Hospital outpatient facility or a magnetic resonance imaging (MRI) facility.
Physician Outpatient Treatment BenefitPays $25 per treatment per calendar year for Covered Charges incurred by a Covered Person in a Hospital Outpatient Clinic, Free-Standing Emergency Care Clinic, or a Physician’s Office, as the result of treatment due to Sickness or emergency care for an injury due to an Accident.
EligibilityThis policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required.
You are eligible to be insured under this Policy if You are on Active Service as an employee of the Policyholder, or as a member or employee of a member of the Policyholder; qualify as an eligible Insured; and meet the definition of Eligibility.
Eligibility means all active full-time employees who are working 18 hours or more per week; covered under Another Medical Plan; and under age 70. (This age limit does not apply, if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year.)
If our underwriting rules are met, You are on Active Service, You are covered under Another Medical Plan and premium has been paid, Your insurance will take effect on the requested Effective Date or the Effective Date assigned by Us upon approval of Your written application, whichever is later.
If You are not on Active Service due to an Accident or Sickness when Your coverage is to take effect, it will take effect on the first day of the calendar month after the date You return to Active Service.
Evidence of coverage under Another Medical Plan may be required.
Policy Benefit HighlightsActive Service means that You are doing in the usual manner all of the regular duties of Your employment on a full-time basis on a scheduled work day; and these duties are being done at one of the places of business where You normally do such duties or at some location to which Your employment sends You. You will be said to be on Active Service on a day which is not a scheduled work day only if You would be able to perform in the usual manner all of the regular duties of Your employment if it were a scheduled work day.
Accident means sudden, unexpected and unintended injury which is independent of any Sickness; over which the Covered Person has no control; and that takes place while the Covered Person's coverage is in force.
Sickness means illness or disease which starts while the Covered Person's coverage is in force and is the direct cause of the loss.
Base PolicyCovered Charges means those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.
In-Hospital BenefitBenefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Other Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Other Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by Another Medical Plan when the Covered Charges are incurred.
Outpatient BenefitsTreatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by Another Medical Plan when the Covered Charges are incurred.
Physician Outpatient Treatment Benefit Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by Another Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.
PremiumsThe premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased.
This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.
Limitations
Summary of Benefits by Plan*
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ExclusionsWe will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under Another Medical Plan, except as provided in the Absence of Other Medical Plan provision or which result from:(a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness;(c) rest care or rehabilitative care and treatment;(d) routine newborn care, including routine nursery charges;(e) voluntary abortion except, with respect to You or Your covered
Dependent spouse: (1) where Your or Your Dependent spouse's life would be
endangered if the fetus were carried to term; or (2) where medical complications have arisen from
abortion;(f) pregnancy of a Dependent child;(g) participation in a riot, civil commotion, civil disobedience, or
unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority;
(h) commission of a felony;(i) participation in a contest of speed in power driven vehicles,
parachuting, or hang gliding;(j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a
regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or
crew member;(k) intoxication; (Whether or not a person is intoxicated is
determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.)
(l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed;
(m) sex changes;(n) experimental treatment, drugs, or surgery;(o) an act of war, whether declared or undeclared, or while
performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.)
(p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers' Compensation.)
(q) mental illness or functional or organic nervous disorders, regardless of the cause;
(r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless:
(1) resulting from an Accident occurring while the Covered Person's coverage is in force and if performed within 12 months of the date of such Accident; or
(2) due to congenital disease or anomaly of a covered newborn child.
(s) routine examinations, such as health exams, periodic check-ups, or routine physicals;
(t) any expense for which benefits are not payable under the Covered Person's Other Medical Plan; or
(u) air or ground ambulance.
Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under Another Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy.
Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent's coverage under Another Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage.
We may end the coverage of any Covered Person who submits a fraudulent claim.
We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder's application requires.
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This is a brief description of the coverage. n For actual benefits and other provisions, please refer to the policy. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. n Policy Form MEDlink® series n Texas n Limited Benefit Medical Expense Supplement Insurance n Employee Brochure n (08/13) n MGM/FBS
Underwritten by:
Limited Benefit Medical Expense Supplement Insurance MEDlink®
Monthly PremiumsIssue Ages 17-54 $1,500 $2,500
Employee $21.50 $28.00
Employee & Spouse $39.50 $51.50
1 Parent Family $36.50 $45.50
2 Parent Family $54.50 $69.00
Issue Ages 55-59 $1,500 $2,500
Employee $32.00 $44.50
Employee & Spouse $59.00 $81.50
1 Parent Family $47.00 $62.00
2 Parent Family $74.00 $99.00
Issue Ages 60-69 $1,500 $2,500
Employee $49.00 $68.50
Employee & Spouse $88.00 $122.50
1 Parent Family $64.00 $86.00
2 Parent Family $103.00 $140.00
Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year.
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Cigna Dental Benefit Summary ESC Region 11 Benefits Co-op High Plan - Account # 3335872 Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.
Benefits Cigna Dental Choice In-Network Out-of-Network
Network Cigna Choice -Radius Cigna Savings -Radius Plan Year Maximum (Class I, II and III expenses)
Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300
Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300
Annual Deductible Individual Family
$50 per person $150 per family
$50 per person $150 per family
Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and Customary Allowances
Plan Pays You Pay Plan Pays You Pay
Class I - Preventive & Diagnostic Care
Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Space Maintainers
100% No Charge 100% No Charge
Class II - Basic Restorative Care
Fillings Sealants Non Routine X-Rays Emergency Care to Relieve Pain Brush Biopsies Oral Surgery – Simple Extractions
70%* 30%* 70%* 30%*
Class III - Major Restorative Care
Crowns/Bridges/Dentures Root Canal Therapy/Endodontics Minor/Major Periodontics Surgical Extractions of Impacted Teeth Oral Surgery - all except simple extractions Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Inlays/Onlays Prosthesis Over Implant
40%* 60%* 40%* 60%*
Class IV - Orthodontia
Lifetime Maximum-$1,000 Limited to Dependent Children only
50% 50% 50% 50%
Important Notes: Dependent/Student age limitation 26/26. Dental Network Savings Program (DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible. Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible
25
medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides: 100% coverage for certain dental procedures, Guidance on behavioral issues related to oral health, Discounts on prescription and non-prescription dental products. For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1 and 2
Cigna Dental PPO Exclusions and Limitations Procedure Exclusions and Limitations Late Entrants Limit 50% coverage on Class III and IV for 12 months Exams Two per Plan year Prophylaxis (Cleanings) Two per Plan year Fluoride 1 per Plan year for people under 19 Histopathologic Exams Various limits per Plan year depending on specific test X-Rays (routine) Bitewings: 2 per Plan year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior teeth. One treatment per tooth every three years up to the age of 14 Space Maintainers Limited to non-Orthodontic treatment
Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non- precious metals. No porcelain or white/tooth colored material on molar crowns or bridges
Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included
asCoveredExpenses Benefit Exclusions: · Services performed primarily for cosmetic reasons · Replacement of a lost or stolen appliance · Replacement of a bridge or denture within five years following the date of its original installation · Replacement of a bridge or denture which can be made useable according to accepted dental standards · Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize
periodontally involved teeth, or restore occlusion · Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars · Bite registrations; precision or semi-precision attachments; splinting · A surgical implant of any type · Instruction for plaque control, oral hygiene and diet · Dental services that do not meet common dental standards · Services that are deemed to be medical services · Services and supplies received from a hospital · Charges which the person is not legally required to pay · Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service · Experimental or investigational procedures and treatments · Any injury resulting from, or in the course of, any employment for wage or profit · Any sickness covered under any workers’ compensation or similar law · Charges in excess of the reasonable and customary allowances · To the extent that payment is unlawful where the person resides when the expenses are incurred; · Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children,
grandparents, and the spouse’s siblings and parents); · For charges which would not have been made if the person had no insurance; · For charges for unnecessary care, treatment or surgery; · To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than
Medicaid; · To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault”
insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.
· In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.
This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. BSD37631 © 2014 Cigna
26
Cigna Dental Benefit Summary ESC Region 11 Benefits Co-op MAC Plan - Account # 3335872 Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.
Benefits Cigna Dental Choice In-Network Out-of-Network
Network Cigna Choice -Radius Cigna Savings -Radius Plan Year Maximum (Class I, II and III expenses)
Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300
Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300
Annual Deductible Individual Family
$50 per person
No Limit
$50 per person
No Limit
Reimbursement Levels** Based on Reduced Contracted Fees Based on Maximum Allowable Charge (In- network fee level)
Plan Pays You Pay Plan Pays You Pay
Class I - Preventive & Diagnostic Care
Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Space Maintainers
100% No Charge 100% No Charge
Class II - Basic Restorative Care
Fillings Sealants Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planning Brush Biopsies Oral Surgery
80%* 20%* 80%* 20%*
Class III - Major Restorative Care
Crowns/Bridges/Dentures Anesthetics Stainless Steel/Resin Crowns Surgical Extractions of Impacted Teeth Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Inlays/Onlays Prosthesis Over Implant
50%* 50%* 50%* 50%*
Class IV - Orthodontia Not covered 100% of your dentist’s usual fees
Not covered 100% of your dentist’s usual fees
Important Notes Dependent/Student Age limitation 26/26. Dental Network Savings Program (DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible
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Dental Oral Health Integration Progr am (OHIP)- All dental customers= Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular d i s e a s e (stroke), diabetes, maternity, c h r o n i c kidney disease, organ transplants, and head and neck cancer radiation. The program provides: 1O0% coverage for certain dental procedures, Guidance on behavioral is sues related to oral health, Discounts on prescription and non- prescription d e n t a l products. For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO ne twork dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according t o the Contracted Fee Schedule but the dentist may balance bill up to their usual fees. #Increase contingent upon receiving Preventive Services in Plan Year 1 +Increase contingent upon receiving Preventive Services in Plan Years 1 and 2
Cigna Dental PPO Exclusions and Limitations Procedure Exclusions and Limitations Late Entrants Limit 50% coverage on Class III and IV for 12 months Exams Two per Plan year Prophylaxis (Cleanings) Two per Plan year Fluoride 1 per Plan year for people under 19 Histopathologic Exams Various limits per Plan year depending on specific test X-Rays (routine) Bitewings: 2 per Plan year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior teeth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment
Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non- precious metals. No porcelain or white/tooth colored material on molar crowns or bridges
Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included
as covered expenses Benefit Exclusions: · Services performed primarily for cosmetic reasons · Replacement of a lost or stolen appliance · Replacement of a bridge or denture within five years following the date of its original installation · Replacement of a bridge or denture which can be made useable according to accepted dental standards · Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize
periodontally involved teeth, or restore occlusion · Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars · Bite registrations; precision or semi-precision attachments; splinting · A surgical implant of any type · Instruction for plaque control, oral hygiene and diet · Dental services that do not meet common dental standards · Services that are deemed to be medical services · Services and supplies received from a hospital · Charges which the person is not legally required to pay · Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service · Experimental or investigational procedures and treatments · Any injury resulting from, or in the course of, any employment for wage or profit · Any sickness covered under any workers’ compensation or similar law · Charges in excess of the reasonable and customary allowances · To the extent that payment is unlawful where the person resides when the expenses are incurred; · Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children,
grandparents, and the spouse’s siblings and parents); · For charges which would not have been made if the person had no insurance; · For charges for unnecessary care, treatment or surgery; · To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than
Medicaid; · To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault”
insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.
· In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.
This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. BSD37632 © 2014 Cigna
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Group Number: 00429340
About Your Benefits:
A visit to your dentist can help you keep a great smile and prevent many health issues. But dental care can be costly and you can befaced with unforeseen expenses. Did you know, a crown can cost as much as $1,4001? Guardian dental insurance will help you payfor it. With access to one of the largest network of dental providers in the country, who agreed to charge negotiated fees for theirservices of up to 30% less than average charges in the same community, you will benefit from lower out-of-pocket costs, quality carefrom screened and reviewed dentist, no claim forms to file, and excellent customer service. Enroll today and smile next time you seeyour dentist!1http://health.costhelper.com/dental-crown.html.
With your DHMO plan, you enjoy negotiated discounts from our network dentists. You pay a fixed copay for each covered service.Out-of-network visits are not covered.
ESC Region 11 Benefits Co-Op All Eligible Employees Benefit Summary
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
Dental Benefit Summary
ESC Region 11 Benefits Co-Op
Your Dental Plan DHMO
Your Network is Managed DentalGuard
Your Monthly premium $12.78
You and spouse $20.21You and child(ren) $27.71
You, spouse and child(ren) $32.91
Calendar year deductible
Individual No deductible
Family limit
Waived for
Charges covered for you (co-insurance) Network onlyPreventive Care You pay a copay for each
Basic Care covered procedure. See
Major Care “Plan Details”, for
Orthodontia more information.
Annual Maximum Benefit Unlimited
Office visit copay $5
Dependent Age Limits(Non-Student/Student) 25/26
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A Sample of Services Covered by Your Plan:
ESC Region 11 Benefits Co-Op All Eligible Employees Benefit Summary
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
DHMO
You PayNetwork only
Anesthesia* Not Covered
Bridges and Dentures $345-355
Cleaning (prophylaxis) $0
Frequency 2 times in 12 months^
Fillings $8
Fluoride Treatments $0
Limits Under Age 18
Inlays, Onlays, Veneers $235-250
Oral Exams $0
Orthodontia $2,285
Limits Adults & Child(ren)
Perio Surgery $255
Periodontal Maintenance $30
Frequency 2 times in 12 months^
(Standard)
Repair & Maintenance ofCrowns, Bridges & Dentures $65-120
Root Canal $95-170
Scaling & Root Planing (per quadrant) $30
Sealants (per tooth) $10
Simple Extractions $8
Single Crowns $230
Surgical Extractions $50-80
X-rays $0
This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. When Orthodontiacoverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required byyour plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status ismaintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings and periodontalmaintenance procedures are combined in a 12 month period. *General Anesthesia – restrictions apply.
Manage Your Benefits:
Go to www.GuardianAnytime.com to access secure informationabout your Guardian benefits including access to an image of yourID Card. Your on-line account will be set up within 30 days afteryour plan effective date..
Find A Dentist:
Visit www.GuardianAnytime.comClick on “Find A Provider”; You will need to know your planand dental network, which can be found on the first page ofyour dental benefit summary.
EXCLUSIONS AND LIMITATIONS
n Important information about Guardian’s Managed DentalGuard Pre-Paid(Florida, New York) Plan, Guardian’s Managed DentalGuard (Colorado) Plan ,Managed DentalGuard Inc.’s (Ohio) Plan, Managed Dental Care’s DHMO(California) Plan, Managed DentalGuard, Inc.’s Managed DentalGuard (NewJersey) Plan, Managed DentalGuard, Inc.’s Managed DentalGuard DHMO(Texas) Plan and Managed DentalGuard -LIBERTY Dental Plan of Nevada, Inc.(Nevada): This plan provides pre-paid dental benefits through a network ofparticipating general dentists and specialty care dentists. All covered servicesmust be provided by the member’s Primary Care Dentist. Specialty careservices are covered only when referred by the member’s Primary CareDentist and approved in advance by Managed DentalGuard. Only thoseservices listed in the plan are covered. Certain services are subject to annual orother periodic limitations. Where orthodontic benefits are specifically included,the plan provides for one course of comprehensive treatment per lifetime, per
member. Unless specifically included, the Managed DentalGuard plan does notprovide orthodontic benefits if comprehensive orthodontic treatment orretention is in progress as of the member’s effective date under the ManagedDentalGuard plan. The services, exclusions and limitations listed here do notconstitute a contract and are a summary only.The Managed DentalGuard plan documents are the final arbiter of coverage.GP-1-MDG1, et al. or GP-1-MDG-FL-1-08, et al. (Florida), GP-1-MDG-NY1,et al. or GP-1-MDG-NY-1-08, et al. (New York), GP-1-MDG-CO-1, et al.(Colorado), GP-1MDC1, et al. or GP-1-MDC-CA-1-08, et al. (California),GP-1-MDG-1-NJ, et al. or GP-1-MDG-NJ-1-08, et al. (New Jersey),GP-1-MDG-TX1, et al. or GP-1-MDG-TX-1-08, et al. (Texas),GP-1-MDG-OH-1, et al. (Ohio), NV110717, et al (Nevada).
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Covered Services Covered Services
Appointments & Diagnostic Services
Periodic oral evaluation, participating general dentist No Charge Inlay - metallic - one surface ^ ** $180.00
Periodic oral evaluation, participating specialty care dentist $10.00 Inlay - metallic - two surfaces ^ ** $235.00
Limited oral evaluation - problem focused, participating general dentist No Charge Inlay - metallic - three or more surfaces ^ ** $235.00
Limited oral evaluation - problem focused, participating specialty care Onlay - metallic - three surfaces ^ ** $250.00
dentist $25.00 Onlay - metallic - four or more surfaces ^ ** $260.00
Comprehensive oral evaluation, participating general dentist No Charge Crown - porcelain/ceramic substrate ^ $250.00
Comprehensive oral evaluation, participating specialty care dentist $25.00 Crown - porcelain fused to high noble metal ^ ** $230.00
Pulp vitality tests No Charge Crown - porcelain fused to predominantly base metal ^ $230.00
Diagnostic casts No Charge Crown - porcelain fused to noble metal ^ $250.00
Office visit - during regular hours - participating general dentist only $5.00 Crown - full cast high noble metal ^ ** $230.00
Consultation (by dentist other than practitioner providing treatment), $30.00 Crown - full cast predominantly base metal ^ $230.00
participating general dentist Crown - full cast noble metal ^ $250.00
Consultation (by dentist other than practitioner providing treatment), $45.00 Crown - 3/4 cast metallic ^ ** $240.00
participating specialty care dentist Crown supporting existing partial denture, in addition to crown $125.00
Office visit for observation - regular hours - no other service performed No Charge Dental lab service - per inlay, onlay, crown or bridge unit $75.00
Emergency office visit - after regularly scheduled office hours $50.00 Pontic - cast high noble metal ^ ** $230.00
Radiographs Pontic - cast metal predominantly base metal ^ $230.00
Intraoral - complete series (including bitewings) $5.00 Pontic - cast noble metal ^ $250.00
Intraoral - periapical - single film No Charge Pontic - porcelain fused to high noble metal ^ ** $230.00
Intraoral - periapical - each additional film No Charge Pontic - porcelain fused to predominantly base metal ^ $230.00
Intraoral - occlusal - each film No Charge Pontic - porcelain fused to noble metal ^ $250.00
Bitewing - single film No Charge Inlay - abutment - metallic - two surfaces ^ ** $260.00
Bitewings - two films No Charge Inlay - abutment - metallic - three or more surfaces ^ ** $265.00
Bitewings - four films No Charge Onlay - abutment - metallic - three surfaces ^ ** $275.00
Panoramic film $5.00 Onlay - abutment - metallic - four or more surfaces ^ ** $290.00
Preventive & Space Maintenance Crown - abutment - porcelain fused to high noble metal ^ ** $230.00
Prophylaxis - adult (first 2 services in any 12 month period) + No Charge Crown - abutment - porcelain fused to predominantly base metal ^ $230.00
Prophylaxis - child (first 2 services in any 12 month period) + No Charge Crown - abutment - porcelain fused to noble metal ^ $250.00
Prophylaxis - adult or child (with or without fluoride)(each additional Crown - abutment - 3/4 cast metallic ^ ** $230.00
service in same 12 month period) + $60.00 Crown - abutment - full cast high noble metal ^ ** $230.00
Topical application of fluoride (including prophylaxis) - child Crown - abutment - full cast predominantly base metal ^ $230.00
(first 2 services in any 12 month period) + No Charge Crown - abutment - full cast noble metal ^ $250.00
Topical application of fluoride (prophylaxis not included) – child Multiple crown and bridge unit treatment plan - per unit $125.00
(first 2 services in any 12 month period) + No Charge Other Restorative Services
Topical application of fluoride (prophylaxis not included) – child Recement inlay $20.00
(each additional service in same 12 month period) + $20.00 Recement crown $20.00
Nutritional counseling for control of dental disease No Charge Prefabricated stainless steel crown $60.00
Oral hygiene instruction No Charge Prefabricated stainless steel crown - permanent tooth $60.00
Sealant - per tooth - molars only $10.00 Prefabricated resin crown $90.00
Sealant - per tooth - non-molars only $35.00 Sedative filling $15.00
Space maintainer - fixed - unilateral $65.00 Core buildup, including any pins $50.00
Space maintainer - fixed - bilateral $110.00 Pin retention - per tooth, in addition to restoration $15.00
Recementation of space maintainer $15.00 Cast post & core $95.00
Restorative Prefabricated post & core $85.00
Amalgam - one surface - primary $10.00 Labial veneer (laminate) - chairside $235.00
Amalgam - two surfaces - primary $10.00 Recement bridge $15.00
Amalgam - three surfaces - primary $15.00 Cast post & core, in addition to abutment $95.00
Amalgam - four or more surfaces - primary $15.00 Prefabricated post & core, in addition to abutment $85.00
Amalgam - one surface - permanent $8.00 Core buildup for abutment, including any pins $55.00
Amalgam - two surfaces - permanent $12.00 Endodontics
Amalgam - three surfaces - permanent $14.00 Pulp cap $10.00
Amalgam - four or more surfaces - permanent $17.00 Therapeutic pulpotomy $30.00
Silicate cement - per restoration $15.00 Root canal - anterior $95.00
Resin/composite - one surface, anterior $20.00 Root canal - bicuspid $160.00
Resin/composite - two surfaces, anterior $25.00 Root canal - molar $170.00
Resin/composite - three surfaces, anterior $30.00 Root canal - retreatment - anterior $310.00
Resin/composite - four or more surfaces or incisal angle, anterior $45.00 Root canal - retreatment - bicuspid $370.00
Composite resin crown, anterior - primary $45.00 Root canal - retreatment - molar $445.00
Resin/composite - one surface, posterior - primary $30.00 Apicoectomy/periradicular surgery – anterior $135.00
Resin/composite - two surfaces, posterior - primary $35.00 Apicoectomy/periradicular surgery - bicuspid - first root $145.00
Resin/composite - three or more surfaces, posterior - primary $40.00 Apicoectomy/periradicular surgery - molar - first root $155.00
Resin/composite - one surface, posterior - permanent $35.00 Apicoectomy/periradicular surgery - each additional root $80.00
Resin/composite - two surfaces, posterior - permanent $50.00 Retrograde filling - per root $35.00
Resin/composite - three or more surfaces, posterior - permanent $70.00 continued on Page 2
3110/3120
6930
6970
6780
6790
3346
3347
3348
3410
2510
2751
2752
2520
2530
2543
2544
2740
2750
2331
2110
1515
1550
2140
1203
1204
1310
2790
2791
0999
2332
2150
2160
2161
2210
2120
2130
2131
2330
1510
0330
0210
0220
0230
1120
1999
1201
2792
1110
0240
0270
0272
0274
9440
2381
2382
2385
2386
2387
3421
3425
3426
3430
Patient
Charge
0120
0120
0140
MDG
Codes++
0140
0150
0150
0460
0470
2335
2336
2380
9310
9310
9430
1330
1351
9999
2810
2999
6199
6210
6211
6212
6240
6241
6242
6520
6530
6543
6544
6750
6751
6752
6791
6792
6999
2910
2920
2930
2931
2932
2940
2950
2951
2952
2954
2960
3330
3220
3310
3320
6972
6973
Managed DentalGuard
Plan Schedule 35-M
Orthodontic Plan Schedule 1
MDG
Codes++
Patient
Charge
V.01265
Page 3131
Covered Services Covered Services
Periodontics Oral Surgery (cont.)
Gingivectomy or gingivoplasty - per quadrant $80.00 Root removal - exposed roots $25.00
Gingivectomy or gingivoplasty - per tooth $25.00 Surgical removal of erupted tooth $30.00
Gingival curettage, surgical - per quadrant - by report $45.00 Removal of impacted tooth - soft tissue $50.00
Gingival flap procedure-including root planing - per quadrant $190.00 Removal of impacted tooth - partially bony $70.00
Clinical crown lengthening - hard tissue $170.00 Removal of impacted tooth - completely bony $80.00
Osseous surgery - including flap entry, closure - per quadrant - Removal of impacted tooth - completely bony, with unusual surgical $90.00
five to eight teeth $255.00 complications
Pedicle soft tissue graft procedure $185.00 Surgical removal of residual tooth roots (cutting procedure) $40.00
Free soft tissue graft procedure (including donor site surgery) $205.00 Tooth reimplantation and/or stabilization of accidentally evulsed
Periodontal scaling & root planing - per quadrant $30.00 tooth $90.00
Full mouth debridement to enable evaluation & diagnosis $35.00 Surgical exposure of impacted or unerupted tooth for orthodontic
Periodontal maintenance procedures (following active therapy) $30.00 reasons $130.00
Unscheduled dressing change (by other than treating dentist) $25.00 Surgical exposure of impacted or unerupted tooth to aid eruption $90.00
Osseous surgery - including flap entry, closure - per quadrant - Biopsy of oral tissue - hard $70.00
one to four teeth $155.00 Biopsy of oral tissue - soft $65.00
Occlusal adjustment - limited - per visit $20.00 Alveoplasty in conjunction with extractions - per quadrant $50.00
Prosthodontics (Removable) Alveoplasty not in conjunction with extractions - per quadrant $70.00
Complete denture (including routine post delivery care) ^ ^ $345.00 Removal of odontogenic cyst/tumor - up to 1.25cm $85.00
Immediate denture (including routine post delivery care) ^ ^ $345.00 Removal of odontogenic cyst/tumor - over 1.25cm $160.00
Partial dentures (including routine post delivery care): Removal of exostosis - maxilla or mandible $125.00
Resin base - including clasps, rests, teeth ^ ^ $310.00 Incision & drainage of intraoral abscess $40.00
Cast metal framework with resin base - including clasps, rests, Frenulectomy (separate procedure) $95.00
teeth ^ ^ $355.00 Orthodontic Treatment (covers 24 months active treatment)
Repairs & adjustments: Comprehensive orthodontic treatment, including fabrication and
Denture adjustments $20.00 insertion of fixed banding appliance and periodic visits, up to 24
Repair denture base ^ ^ ^ $45.00 months; dependent child to age 18 (as determined by the
Replace missing or broken teeth - per tooth ^ ^ ^ $35.00 Member’s age on the date of banding) $2,285.00
Repair or replace clasp ^ ^ ^ $60.00 Comprehensive orthodontic treatment, including fabrication and
Add tooth to existing partial ^ ^ ^ $45.00 insertion of fixed banding appliance and periodic visits, up to 24
Add clasp to existing partial ^ ^ ^ $45.00 months; employee, spouse, or dependent child over age 18
Rebase denture ^ ^ ^ $125.00 (as determined by the Member’s age on the date of banding) $2,285.00
Reline denture (chairside) $65.00 Orthodontic evaluation and consultation $100.00
Reline denture (laboratory) ^ ^ ^ $120.00 Periodic comprehensive orthodontic treatment visit No Charge
Interim partial denture (stayplate) $95.00 Orthodontic retention $415.00
Tissue conditioning $30.00 Orthodontic treatment plan and records, including x-rays, study model $150.00
Dental lab service - each new complete, immediate, or partial denture $165.00 Miscellaneous Services
Dental lab service - denture repair, rebase or reline - per denture $35.00 Palliative (emergency) treatment - per visit $15.00
Oral Surgery Local anesthesia No Charge
Extraction - single tooth $8.00 External bleaching - per arch - take home bleaching only $165.00
Extraction - each additional tooth $9.00
++
+
^
^ ^
^ ^ ^
**
Plan Schedule 35-M is only valid for Covered Services rendered by Participating Dentists in the State of Texas.
Orthodontic Plan Schedule 1 is only valid for Authorized Services rendered by Participating Orthodontic Specialty Care Dentists in the State of Texas.
see codes 1204 and 1999 for the applicable patient charge
There is an additional dental lab service patient charge for these procedures. See code 5899 for the applicable patient charge.
There is an additional dental lab service patient charge for these procedures. See code 5999 for the applicable patient charge.
If high noble metal is used, there may be an additional patient charge for the actual cost of the high noble metal. The total patient charge for high noble metal plus the applicable dental lab service
Covered Services are subject to exclusions, limitations and Plan provisions. Other codes may be used to describe Covered Services.
The patient charges for codes 1110, 1120, 1201 and 1203 are limited to the first two services in any 12 month period. For each additional service in the same 12 month period,
There is an additional dental lab service patient charge for these procedures. See code 6199 for the applicable patient charge.
5510/5610
5520/5640
5630
5211/5212
4920
Managed DentalGuard
Plan Schedule 35-M
Orthodontic Plan Schedule 1
Patient
Charge
charge may not exceed the general dentist’s actual lab
MDG Codes++
Patient
Charge MDG Codes++
5999
5750/51/60/61
5820/5821
5850/5851
5899
5410/11/21/22
5650
5660
5710/11/20/21
5730/31/40/41
4999
5213/5214
9951
5110/5120
5130/5140
4271
4341
4355
4910
4240
4249
4260
4270
4210
4211
4220
7110
7120
7130
7210
7220
7230
7240
7241
7250
7270
7280
7281
7285
7286
7310
7320
7450
7451
8680
7510
7960
8070/8080/8090
8070/8080/8090
8660
8670
7470
9972
8999
9110
9215
V.01265
Page32
Effective 9/1/2014
BLOCK VISION, INC.
BENEFIT ILLUSTRATION ESC REGION 11 BENEFITS CO-OP #320580 Platinum $125 VISION PLAN
$10 Exam $10 Eyewear Copayments Full Service Service / Material In-Network Provider Out-of-Network Provider
Vision Examination: Paid in full1 Up to: $35.00 Retail Value1 Frame: Up to: $125.00 Retail Value1 Up to: $70.00 Retail Value1 Lenses: (Clear, Standard, Glass or Plastic)
Single Vision (per pair) Paid in full1 Up to: $25.00 Retail Value1 Bifocal (per pair) Paid in full1 Up to: $40.00 Retail Value1 Trifocal (per pair) 2 Paid in full1 Up to: $45.00 Retail Value1 Lenticular (per pair) Paid in full1 Up to: $80.00 Retail Value1 Contact Lenses:
3
Elective Up to $150.001 Up to: $80.00 Retail Value1
Medically Required Paid in full1 Up to: $150.00 Retail Value1 Laser Vision Correction: $200.00 allowance (in or out of network) - (Laser Vision Correction is in lieu of the eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations)
1 After applicable copayment listed above is fulfilled.
2 Member pays difference in retail price between standard trifocal lenses and progressive lenses.
3 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglasses.
Coverage to include all contact lens types (i.e. standard daily wear, extended wear, disposable, toric, gas permeable, and bifocal). Frequency:
Vision Examination Once every 12 Months Frame Once every 12 Months Lenses Once every 12 Months Contact Lenses (in lieu of eyeglasses) Once every 12 Months
Rates:
Voluntary Participation Monthly Employee $ 8.86 Employee + Spouse $15.09
Employee + Child(ren) $15.97 Family $23.95
Non-Covered Eyewear Discount: Members may also receive a discount of 20% from an in-network provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Wal-Mart Vision Center does not qualify for this additional discount because of Wal-Mart’s “Always Low Prices” policy.
Here’ s Look ing a t You
FOR MORE INFORMATION PLEASE CONTACT US TOLL-FREE AT
(866) 265-0517 OR VISIT OUR WEBSITE AT www.blockvision.com
33
Wh
at
pla
n o
pti
on
s are
avail
ab
le?
ES
C R
egio
n 11
Ben
efits
Co-
op #
3205
80 e
mpl
oyee
s ar
e be
ing
offe
red
our P
latin
um $
125
plan
. Th
e Pl
atin
um $
125
plan
inc
lude
s a
rout
ine/
basi
c vi
sion
exa
min
atio
n ye
arly
with
the
be
nefit
per
iod
mea
sure
d fro
m d
ate
of s
ervi
ce.
The
eyew
ear
bene
fit p
rovi
des
cove
rage
for
le
nses
or
cont
acts
eve
ry y
ear
with
the
ben
efit
perio
d m
easu
red
from
dat
e of
ser
vice
and
pr
ovid
es u
p to
$12
5 co
vera
ge fo
r fra
mes
eve
ry y
ear.
H
ow
do I
en
roll
in
th
is p
lan
?
You
mus
t com
plet
e th
e en
rollm
ent f
orm
fur
nish
ed to
you
. A
t enr
ollm
ent,
you
shou
ld m
ark
your
cov
erag
e se
lect
ion
(i.e.
em
ploy
ee, e
mpl
oyee
+ sp
ouse
, em
ploy
ee+
child
(ren
) or
fam
ily).
If
you
sele
ct e
mpl
oyee
+ sp
ouse
, em
ploy
ee+
child
(ren
), or
fam
ily, b
e su
re to
incl
ude
all t
he
info
rmat
ion
requ
este
d fo
r cov
ered
dep
ende
nts,
incl
udin
g bi
rth d
ates
. W
hat
are
th
e d
epen
den
t ag
e el
igib
ilit
y r
equ
irem
en
ts u
nd
er t
his
pla
n?
You
r or Y
our s
pous
e’s u
nmar
ried:
(a) n
atur
al c
hild
; (b)
step
child
; (c)
fost
er c
hild
; (d)
ado
pted
ch
ild o
r chi
ld d
urin
g pe
nden
cy o
f ado
ptio
n; (e
) a c
hild
for w
hom
You
are
requ
ired
by a
cou
rt or
der,
adm
inis
trativ
e or
der o
r a m
edic
al su
ppor
t ord
er to
pro
vide
hea
lth in
sura
nce
cove
rage
; or
(f) g
rand
child
who
is d
epen
dent
on
you
for f
eder
al in
com
e ta
x pu
rpos
es.
Such
chi
ld(r
en)
mus
t: (1
) be
less
than
26
year
s old
; or (
2) h
ave
beco
me
inca
pabl
e of
self-
supp
ort b
ecau
se o
f m
enta
l ret
arda
tion
or p
hysi
cal h
andi
cap
whi
le in
sure
d un
der t
his C
ertif
icat
e an
d pr
ior t
o re
achi
ng a
ge 2
6. T
he c
hild
mus
t be
depe
nden
t on
You
for s
uppo
rt an
d m
aint
enan
ce.
We
mus
t re
ceiv
e pr
oof o
f inc
apac
ity w
ithin
31
days
afte
r cov
erag
e w
ould
oth
erw
ise
term
inat
e. T
hen,
co
vera
ge w
ill c
ontin
ue fo
r as l
ong
as y
our i
nsur
ance
stay
s in
forc
e an
d th
e ch
ild re
mai
ns
inca
paci
tate
d. A
dditi
onal
pro
of m
ay b
e re
quire
d fro
m ti
me
to ti
me
but n
ot m
ore
ofte
n th
an
once
a y
ear a
fter t
he c
hild
atta
ins 2
6.
How
do I
use
th
is p
lan
?
With
you
r vis
ion
bene
fit, c
hoos
e a
prov
ider
from
the
In-N
etw
ork
Prov
ider
Dire
ctor
y. P
rese
nt
your
ID
ca
rd
for
serv
ices
at
th
e tim
e of
se
rvic
e.
EXC
EPT
FOR
A
NY
A
PPLI
CA
BLE
C
OPA
YM
ENT,
DO
NO
T PA
Y Y
OU
R I
N-N
ETW
OR
K P
RO
VID
ER F
OR
SER
VIC
ES O
R E
YEW
EAR
C
OV
ERED
BY
YO
UR
BLO
CK
VIS
ION
BEN
EFIT
. If
you
choo
se a
n O
ut-o
f-Net
wor
k pr
ovid
er, y
ou w
ill b
e ex
pect
ed to
pay
the
doct
or fo
r ser
vice
s re
ceiv
ed.
You
will
then
nee
d to
send
the
orig
inal
rece
ipt f
rom
you
r Out
-of-N
etw
ork
doct
or to
B
lock
Vis
ion
for
reim
burs
emen
t. B
lock
Vis
ion
will
rev
iew
you
r el
igib
ility
and
sen
d th
e ap
prop
riate
reim
burs
emen
t to
you.
Con
tact
lens
es a
nd re
late
d pr
ofes
sion
al s
ervi
ces
with
a re
tail
valu
e of
up
to $
150
are
cove
red
in li
eu o
f ey
egla
sses
. C
over
age
incl
udes
the
com
plet
e co
ntac
t len
s pa
ckag
e (c
onta
ct le
nses
an
d re
late
d pr
ofes
sion
al s
ervi
ces
spec
ific
to c
onta
ct l
ens
fittin
g, e
valu
atio
n an
d fo
llow
-up)
. M
embe
rs re
ceiv
e a
$150
reta
il al
low
ance
tow
ard
the
purc
hase
of c
onta
ct le
nses
that
reta
il fo
r m
ore
than
$15
0.
Am
I a
ble
to o
bta
in e
yeg
lass
es a
nd
co
nta
ct l
en
ses
in t
he
sam
e y
ear?
No.
Blo
ck V
isio
n’s
plan
pro
vide
s co
vera
ge f
or e
yegl
asse
s or
con
tact
len
ses,
but
not
both
, w
ithin
the
stat
ed b
enef
it pe
riod.
W
hat
is t
he
dif
fere
nce
bet
wee
n a
n O
pto
met
rist
an
d O
ph
thalm
olo
gis
t?
Bot
h ar
e kn
own
as e
ye d
octo
rs a
nd b
oth
perfo
rm e
ye e
xam
inat
ions
. A
n O
ptom
etris
t is
an e
ye
spec
ialis
t. A
n O
phth
alm
olog
ist i
s an
"ey
e su
rgeo
n."
Som
e of
our
In-
Net
wor
k O
ptom
etris
ts
are
now
lice
nsed
to tr
eat e
ye in
fect
ions
, pre
scrib
e m
edic
atio
n an
d re
mov
e fo
reig
n bo
dies
. H
ow
wil
l th
e B
lock
Vis
ion
provid
er d
eterm
ine
wh
at
I a
m e
lig
ible
to r
ecei
ve?
Em
ploy
ees
elec
ting
sing
le c
over
age
will
rec
eive
1 I
D c
ard.
Em
ploy
ees
elec
ting
empl
oyee
+ sp
ouse
, em
ploy
ee+
child
(ren
), or
fam
ily c
over
age
will
be
issu
ed 2
ID c
ards
. Th
e B
lock
Vis
ion
ID c
ard
enab
les
the
Blo
ck V
isio
n pr
ovid
er t
o ac
cess
Blo
ck V
isio
n’s
com
pute
r sy
stem
to
dete
rmin
e w
hat y
ou a
re e
ligib
le to
rec
eive
. Pl
ease
be
awar
e th
at y
our
elig
ibili
ty w
ith B
lock
V
isio
n is
cal
cula
ted
on a
dat
e of
ser
vice
- to
dat
e of
ser
vice
met
hod,
not
cal
enda
r ye
ar.
For
exam
ple,
if y
ou a
re e
ntitl
ed to
an
exam
onc
e ea
ch 1
2 m
onth
s and
rece
ive
your
firs
t exa
m o
n 3-
11-1
4, y
ou w
ill b
ecom
e el
igib
le a
gain
for a
new
exa
m o
n 3-
11-1
5.
If I
wea
r d
isp
osa
ble
co
nta
ct l
en
ses,
mu
st I
use
my
en
tire
ben
efit
at
on
e ti
me?
N
o.
You
may
con
tinue
to
mak
e us
e of
the
rem
aini
ng a
mou
nt o
f yo
ur c
onta
ct l
ens
bene
fit
durin
g th
e be
nefit
freq
uenc
y st
ated
in y
our p
lan.
For
exa
mpl
e, if
you
nee
d di
spos
able
lens
es
once
eve
ry th
ree
mon
ths,
then
that
is th
e w
ay y
ou o
btai
n yo
ur le
nses
in th
e B
lock
Vis
ion
plan
un
til s
uch
time
as y
our b
enef
it m
axim
um h
as b
een
reac
hed.
Any
rem
aini
ng b
enef
it va
lues
at
the
end
of th
e be
nefit
per
iod
are
not c
arrie
d ov
er to
the
next
ben
efit
perio
d.
Wh
at
typ
e of
eyeg
lass
len
ses
am
I e
lig
ible
for?
W
hat
ab
ou
t P
rog
ress
ive
Len
ses?
T
ints
?
All
Blo
ck V
isio
n’s
plan
s co
ver
clea
r, st
anda
rd g
lass
or
plas
tic l
ense
s, w
ith s
ingl
e vi
sion
, bi
foca
l or
trif
ocal
pre
scrip
tions
. Y
ou m
ay c
hoos
e to
upg
rade
you
r le
nses
by
payi
ng t
he
diffe
renc
e ov
er a
nd a
bove
the
stan
dard
lens
pric
e. F
or e
xam
ple,
if y
ou w
ant a
n an
ti-re
flect
ive
coat
ing
on y
our l
ense
s, th
e pl
an w
ill p
ay fo
r the
sta
ndar
d le
ns a
nd y
ou a
re re
spon
sibl
e fo
r the
co
st o
f the
ant
i-ref
lect
ive
coat
ing.
If y
ou w
ould
like
pro
gres
sive
lens
es, y
our b
enef
it w
ill p
ay
for s
tand
ard
trifo
cal l
ense
s an
d yo
u w
ill p
ay a
ny a
mou
nt o
ver a
nd a
bove
the
stan
dard
trifo
cal
pric
e.
Tint
ing,
coa
ting
and
any
othe
r "a
dditi
ons"
to
your
len
ses
are
adde
d at
you
r ow
n ex
pens
e.
Blo
ck V
isio
n w
ill p
ay f
or t
he c
lear
, st
anda
rd g
lass
or
plas
tic l
ense
s w
ith s
ingl
e vi
sion
, bifo
cal o
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34
Educator Select Income Protection
Plan Insurance Highlights
EB-975
ESC Region 11 Benefits Cooperative
Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.
Your Plan
Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.
Guarantee Issue Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period.
Newly Hired Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period.
Benefits are subject to the pre-existing condition exclusion referenced later in this document.
Please see your Plan Administrator for your eligibility date.
Benefit Amount
You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $7,500. Please see your Plan Administrator for the definition of monthly earnings.
The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).
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Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits.
You may choose an Elimination Period (injury/sickness) of 0/7, 14/14, 30/30, 60/60, 90/90 or 180/180 days.
If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)
Benefit Duration Your duration of benefits is based on your age when the disability occurs.
You may choose one of the following duration options:
Plan A: ADEA II: Your duration of benefits is based on the following table: Age at Disability Maximum Duration of Benefits Less than age 60 To age 65, but not less than 5 years Age 60 through 64 5 years Age 65 through 69 To age 70, but not less than 1 year Age 70 and over 1 year
OR: Plan B: 2 YR ADEA: Your duration of benefits is based on the following table: Age at Disability Maximum Duration of Benefits Less than age 68 2 years Age 68 To age 70, but not less than 1 year Age 69 and over 1 year
Federal Income Taxation The taxability of benefits depends on how premium was taxed during the
plan year in which you become disabled. If you paid 100% of the premium for the plan year with post-tax dollars, your benefits will not be taxed. If premium for the plan year is paid with pre-tax dollars, your benefits will be taxed. If premium for the plan year is paid partially with post-tax dollars and partially with pre-tax dollars, or if you and your Employer share in the cost, then a portion of your benefits will be taxed.
Additional Benefits
Work/Life Balance Employee Assistance
Program1
Work-life balance is a comprehensive resource providing access to professional assistance for a wide range of personal and work-related issues. The service is available to you and your family members twenty-four hours a day, 365 days a year, and provides resources to help employees find solutions to everyday issues such as financing a car or selecting child care, as well as more serious problems such as alcohol or drug addiction, divorce, or relationship problems. Services include: toll-free phone access to master’s-level consultants, up to
36
three face-to-face sessions to help with more serious issues; and online resources. There is no additional charge for utilizing the program. Participation is confidential and strictly voluntary, and employees do not have to have filed a disability claim or be receiving benefits to use the program. However, if you become disabled and are receiving benefits, Unum's On Claim Support can provide additional resources including: coaching on how to communicate effectively with medical personnel, conducting consumer research for medical equipment and supplies, assessing emotional needs and locating counseling resources.
Return to Work/ Work Incentive Benefit
Unum supports efforts that enable a disabled employee to remain on the job or return to work as soon as possible. If you are disabled but working part time with monthly disability earnings of 20% or more of your indexed monthly earnings, during the first 12 months, the monthly benefit will not be reduced by any earnings until the gross disability payment plus your disability earnings, exceeds 100% of your indexed monthly earnings. The monthly benefit will then be reduced by that amount.
Rehabilitation and Return to Work Assistance
Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will make the final determination of your eligibility for participation in the program, and will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you. This program may include, but is not limited to the following benefits: coordination with your Employer to assist your return to work; adaptive equipment or job accommodations to allow you to work; vocational evaluation to determine how your disability may impact
your employment options; job placement services; resume preparation; job seeking skills training; or education and retraining expenses for a new occupation.
If you are participating in a Rehabilitation and Return to Work Assistance program, we will also pay an additional disability benefit of 10% of your gross disability payment to a maximum of $1,000 per month. In addition, we will make monthly payments to you for 3 months following the date your disability ends, if we determine you are no longer disabled while: you are participating in a Rehabilitation and Return to Work Assistance
program; and you are not able to find employment.
(This benefit is not allowed in New Jersey.)
Worksite Modification If a worksite modification will enable you to remain at work or return to work, a designated Unum professional will assist in identifying what’s needed. A written agreement must be signed by you, your employer and Unum, and we will reimburse your employer for the greater of $1,000 or the equivalent of two months of your disability benefit.
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Waiver of Premium After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving disability benefits.
Survivor Benefit
Unum will pay your eligible survivor a lump sum benefit equal to 3 months of your gross disability payment.
This benefit will be paid if, on the date of your death, your disability had continued for 180 or more consecutive days, and you were receiving or were entitled to receive payments under the plan. If you have no eligible survivors, payment will be made to your estate, unless there is none. In that case, no payment will be made. However, we will first apply the survivor benefit to any overpayment which may exist on your claim.
You may receive your survivor benefit prior to your death if you are receiving monthly payments and your physician certifies in writing that you have been diagnosed as terminally ill and your life expectancy has been reduced to less than 12 months. This benefit is only payable once and if you elect to receive this benefit, no survivor benefit will be payable to your eligible survivor upon your death. (Note this “Accelerated Survivor Benefit” is not available in Connecticut.)
Dependent Care Expense Benefit
If you are disabled and participating in Unum’s Rehabilitation and Return to Work Assistance program, Unum will pay a Dependent Care Expense Benefit when you are disabled and you provide satisfactory proof that you: are incurring expenses to provide care for a child under the age of 15; and/or start incurring expenses to provide care for a child age 15 or
older or a family member who needs personal care assistance.
The payment will be $350 per month per dependent, to a maximum of $1,000 per month for all dependent care expenses combined.
Education Benefit If you are disabled and receiving monthly disability benefits, you may receive an additional monthly Education Benefit of $200 for each child who is an eligible student. Benefits will be payable in between terms provided the eligible student is enrolled for the next scheduled term.
Eligible student means your unmarried dependent child(ren) who are: less than 25 years of age; and attending an accredited post-secondary school beyond the 12th grade
level on a full-time basis.
Other Important Provisions
Pre-existing Condition Exclusion
Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if:
you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date of coverage.
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Continuity of Coverage If you are actively at work at the time you convert to Unum’s plan and
become disabled due to a pre-existing condition, benefits may be payable if you were: in active employment and insured under the plan on its effective date; and insured by the prior plan at the time of change. To receive a payment, you must satisfy the pre-existing condition under the Unum policy or the prior carrier’s policy. If you satisfy Unum’s pre-existing condition provision, payments will be determined by the Unum policy. If you only satisfy the pre-existing condition provision for the prior carrier’s policy, the claim will be administered according to the Unum policy. However,
the payments will be the lesser of the benefit payable under the terms of the prior plan or the benefit under the Unum plan;
the elimination period will be the shorter of the elimination period under the prior plan or the elimination period under the Unum plan; and
benefits will end on the earlier of the end of the maximum period of payment under the Unum plan or the date benefits would have ended under the prior plan.
Note: COC will not apply to new hires unless, through your previous employer, you were insured through Unum on the Educator Select product and underwriting approval for a exception is obtained. Please see your plan administrator for additional details.
Definition of Disability
You are disabled when Unum determines that:
you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury;
you have a 20% or more loss in indexed monthly earnings due to the same sickness or injury; and
during the elimination period you are unable to perform any of the material and substantial duties of your regular occupation.
After benefits have been paid for 24 months, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. You must be under the regular care of a physician in order to be considered disabled.
Gainful Occupation
Gainful occupation means an occupation that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds 80% of your indexed monthly earnings if you are working or 60% of your indexed monthly earnings if you are not working.
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Benefit Integration Your disability benefit will be reduced by deductible sources of income and any earnings you have while disabled. Your gross disability payment will be reduced immediately by such items as disability income or other amounts you receive or are entitled to receive from sabbatical or assault leave plans and the amount of earnings you receive from an extended sick leave plan as described in Louisiana Revised Statutes or any other act or law with similar intent. After you have received monthly disability payments for 6 months, your gross disability payment will be reduced by such items as additional deductible sources of income you receive or are entitled to receive under: state compulsory benefit laws; automobile liability insurance; legal judgments and settlements; certain retirement plans; salary continuation or sick leave plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs.
Regardless of deductible sources of income, an employee who qualifies for disability benefits is guaranteed to receive a minimum benefit amount of the greater of $100 or 10% of the gross disability payment.
Mental Illness/Self-Reported Symptoms
The lifetime cumulative maximum benefit period for all disabilities due to mental illness and disabilities based primarily on self-reported symptoms is 12 months. Only 12 months of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous and/or are not related. Payments would continue beyond 12 months only if you are confined to a hospital or institution as a result of the disability.
Instances When Benefits Would Not Be Paid
Benefits will not be paid for disabilities caused by, contributed to by, or resulting from:
intentionally self-inflicted injuries; active participation in a riot; commission of a crime for which you have been convicted; loss of professional license, occupational license or certification; pre-existing conditions (see definition). an occupational injury or sickness (this will not apply to a partner or sole proprietor who cannot be covered by law under Workers' Compensation or any similar law);
Unum will not cover a disability due to war, declared or undeclared, or any act of war.
Unum will not pay a benefit for any period of disability during which you are incarcerated.
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Termination of Coverage Your coverage under the policy ends on the earliest of the following: The date the policy or plan is cancelled; The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required
contributions; The later of the last day you are in active employment except as
provided under the covered layoff or leave of absence provision; or if applicable, the last day of your contract with your Employer but not beyond the end of your Employer’s current school contract year.
Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.
Next Steps
How to Apply/ Effective Date of Coverage
Current employees: To apply for coverage, complete your enrollment form by the enrollment deadline. Your effective date of coverage is the policy effective date of your school, or the day after you complete your waiting period, whichever is later.
Newly Hired Employees: To apply for coverage, complete your enrollment form within 60 days of your eligibility date. Please see your Plan Administrator for your effective date.
If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.
Delayed Effective Date of Coverage
If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.
Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. 1 Work-life balance employee assistance program and On-Claim Support services are provided by Ceridian Corporation. Services are available with selected Unum insurance offerings. Exclusions, limitations and prior notice requirements may apply, and service features, terms and eligibility criteria are subject to change. The services are not valid after termination of coverage and may be withdrawn at any time. Please contact your Unum representative for full details. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ©2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
41
ESC REGION 11 BENEFITS COOPERATIVE Costs below are based on a Monthly payroll deduction
(Employer billing mode is based on 12 Payments per year)
Option 3
Product: Plan A Plan B Educator Select Income Protection Plan
ADEA II Duration of Benefits 2 YR ADEA Duration of Benefits
Elimination Period (Days) Elimination Period (Days) Injury (Days) 0* 14* 30* 60 90 180 0* 14* 30* 60 90 180
Sickness (Days) 7* 14* 30* 60 90 180 7* 14* 30* 60 90 180 Annual
EarningsMonthly Earnings
Maximum Monthly Benefit
3600 300 200 6.82 5.78 4.94 3.96 2.24 1.56 5.62 4.56 3.56 2.38 1.22 0.74 5400 450 300 10.23 8.67 7.41 5.94 3.36 2.34 8.43 6.84 5.34 3.57 1.83 1.11 7200 600 400 13.64 11.56 9.88 7.92 4.48 3.12 11.24 9.12 7.12 4.76 2.44 1.48 9000 750 500 17.05 14.45 12.35 9.90 5.60 3.90 14.05 11.40 8.90 5.95 3.05 1.85 10800 900 600 20.46 17.34 14.82 11.88 6.72 4.68 16.86 13.68 10.68 7.14 3.66 2.22 12600 1050 700 23.87 20.23 17.29 13.86 7.84 5.46 19.67 15.96 12.46 8.33 4.27 2.59 14400 1200 800 27.28 23.12 19.76 15.84 8.96 6.24 22.48 18.24 14.24 9.52 4.88 2.96 16200 1350 900 30.69 26.01 22.23 17.82 10.08 7.02 25.29 20.52 16.02 10.71 5.49 3.33 18000 1500 1000 34.10 28.90 24.70 19.80 11.20 7.80 28.10 22.80 17.80 11.90 6.10 3.70 19800 1650 1100 37.51 31.79 27.17 21.78 12.32 8.58 30.91 25.08 19.58 13.09 6.71 4.07 21600 1800 1200 40.92 34.68 29.64 23.76 13.44 9.36 33.72 27.36 21.36 14.28 7.32 4.44 23400 1950 1300 44.33 37.57 32.11 25.74 14.56 10.14 36.53 29.64 23.14 15.47 7.93 4.81 25200 2100 1400 47.74 40.46 34.58 27.72 15.68 10.92 39.34 31.92 24.92 16.66 8.54 5.18 27000 2250 1500 51.15 43.35 37.05 29.70 16.80 11.70 42.15 34.20 26.70 17.85 9.15 5.55 28800 2400 1600 54.56 46.24 39.52 31.68 17.92 12.48 44.96 36.48 28.48 19.04 9.76 5.92 30600 2550 1700 57.97 49.13 41.99 33.66 19.04 13.26 47.77 38.76 30.26 20.23 10.37 6.29 32400 2700 1800 61.38 52.02 44.46 35.64 20.16 14.04 50.58 41.04 32.04 21.42 10.98 6.66 34200 2850 1900 64.79 54.91 46.93 37.62 21.28 14.82 53.39 43.32 33.82 22.61 11.59 7.03 36000 3000 2000 68.20 57.80 49.40 39.60 22.40 15.60 56.20 45.60 35.60 23.80 12.20 7.40 37800 3150 2100 71.61 60.69 51.87 41.58 23.52 16.38 59.01 47.88 37.38 24.99 12.81 7.77 39600 3300 2200 75.02 63.58 54.34 43.56 24.64 17.16 61.82 50.16 39.16 26.18 13.42 8.14 41400 3450 2300 78.43 66.47 56.81 45.54 25.76 17.94 64.63 52.44 40.94 27.37 14.03 8.51 43200 3600 2400 81.84 69.36 59.28 47.52 26.88 18.72 67.44 54.72 42.72 28.56 14.64 8.88 45000 3750 2500 85.25 72.25 61.75 49.50 28.00 19.50 70.25 57.00 44.50 29.75 15.25 9.25 46800 3900 2600 88.66 75.14 64.22 51.48 29.12 20.28 73.06 59.28 46.28 30.94 15.86 9.62 48600 4050 2700 92.07 78.03 66.69 53.46 30.24 21.06 75.87 61.56 48.06 32.13 16.47 9.99 50400 4200 2800 95.48 80.92 69.16 55.44 31.36 21.84 78.68 63.84 49.84 33.32 17.08 10.36 52200 4350 2900 98.89 83.81 71.63 57.42 32.48 22.62 81.49 66.12 51.62 34.51 17.69 10.73 54000 4500 3000 102.30 86.70 74.10 59.40 33.60 23.40 84.30 68.40 53.40 35.70 18.30 11.10 55800 4650 3100 105.71 89.59 76.57 61.38 34.72 24.18 87.11 70.68 55.18 36.89 18.91 11.47 57600 4800 3200 109.12 92.48 79.04 63.36 35.84 24.96 89.92 72.96 56.96 38.08 19.52 11.84 59400 4950 3300 112.53 95.37 81.51 65.34 36.96 25.74 92.73 75.24 58.74 39.27 20.13 12.21 61200 5100 3400 115.94 98.26 83.98 67.32 38.08 26.52 95.54 77.52 60.52 40.46 20.74 12.58 63000 5250 3500 119.35 101.15 86.45 69.30 39.20 27.30 98.35 79.80 62.30 41.65 21.35 12.95 64800 5400 3600 122.76 104.04 88.92 71.28 40.32 28.08 101.16 82.08 64.08 42.84 21.96 13.32 66600 5550 3700 126.17 106.93 91.39 73.26 41.44 28.86 103.97 84.36 65.86 44.03 22.57 13.69 68400 5700 3800 129.58 109.82 93.86 75.24 42.56 29.64 106.78 86.64 67.64 45.22 23.18 14.06 70200 5850 3900 132.99 112.71 96.33 77.22 43.68 30.42 109.59 88.92 69.42 46.41 23.79 14.43 72000 6000 4000 136.40 115.60 98.80 79.20 44.80 31.20 112.40 91.20 71.20 47.60 24.40 14.80 73800 6150 4100 139.81 118.49 101.27 81.18 45.92 31.98 115.21 93.48 72.98 48.79 25.01 15.17 75600 6300 4200 143.22 121.38 103.74 83.16 47.04 32.76 118.02 95.76 74.76 49.98 25.62 15.54 77400 6450 4300 146.63 124.27 106.21 85.14 48.16 33.54 120.83 98.04 76.54 51.17 26.23 15.91 79200 6600 4400 150.04 127.16 108.68 87.12 49.28 34.32 123.64 100.32 78.32 52.36 26.84 16.28 81000 6750 4500 153.45 130.05 111.15 89.10 50.40 35.10 126.45 102.60 80.10 53.55 27.45 16.65 82800 6900 4600 156.86 132.94 113.62 91.08 51.52 35.88 129.26 104.88 81.88 54.74 28.06 17.02 84600 7050 4700 160.27 135.83 116.09 93.06 52.64 36.66 132.07 107.16 83.66 55.93 28.67 17.39 86400 7200 4800 163.68 138.72 118.56 95.04 53.76 37.44 134.88 109.44 85.44 57.12 29.28 17.76 88200 7350 4900 167.09 141.61 121.03 97.02 54.88 38.22 137.69 111.72 87.22 58.31 29.89 18.13 90000 7500 5000 170.50 144.50 123.50 99.00 56.00 39.00 140.50 114.00 89.00 59.50 30.50 18.50 91800 7650 5100 173.91 147.39 125.97 100.98 57.12 39.78 143.31 116.28 90.78 60.69 31.11 18.87 93600 7800 5200 177.32 150.28 128.44 102.96 58.24 40.56 146.12 118.56 92.56 61.88 31.72 19.24
REF #: 2190398
* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement.Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.
42
Product: Plan A Plan B Educator Select Income Protection Plan
ADEA II Duration of Benefits 2 YR ADEA Duration of Benefits
Elimination Period (Days) Elimination Period (Days) Injury (Days) 0* 14* 30* 60 90 180 0* 14* 30* 60 90 180
Sickness (Days) 7* 14* 30* 60 90 180 7* 14* 30* 60 90 180 Annual
EarningsMonthly Earnings
Maximum Monthly Benefit
95400 7950 5300 180.73 153.17 130.91 104.94 59.36 41.34 148.93 120.84 94.34 63.07 32.33 19.61 97200 8100 5400 184.14 156.06 133.38 106.92 60.48 42.12 151.74 123.12 96.12 64.26 32.94 19.98 99000 8250 5500 187.55 158.95 135.85 108.90 61.60 42.90 154.55 125.40 97.90 65.45 33.55 20.35 100800 8400 5600 190.96 161.84 138.32 110.88 62.72 43.68 157.36 127.68 99.68 66.64 34.16 20.72 102600 8550 5700 194.37 164.73 140.79 112.86 63.84 44.46 160.17 129.96 101.46 67.83 34.77 21.09 104400 8700 5800 197.78 167.62 143.26 114.84 64.96 45.24 162.98 132.24 103.24 69.02 35.38 21.46 106200 8850 5900 201.19 170.51 145.73 116.82 66.08 46.02 165.79 134.52 105.02 70.21 35.99 21.83 108000 9000 6000 204.60 173.40 148.20 118.80 67.20 46.80 168.60 136.80 106.80 71.40 36.60 22.20 109800 9150 6100 208.01 176.29 150.67 120.78 68.32 47.58 171.41 139.08 108.58 72.59 37.21 22.57 111600 9300 6200 211.42 179.18 153.14 122.76 69.44 48.36 174.22 141.36 110.36 73.78 37.82 22.94 113400 9450 6300 214.83 182.07 155.61 124.74 70.56 49.14 177.03 143.64 112.14 74.97 38.43 23.31 115200 9600 6400 218.24 184.96 158.08 126.72 71.68 49.92 179.84 145.92 113.92 76.16 39.04 23.68 117000 9750 6500 221.65 187.85 160.55 128.70 72.80 50.70 182.65 148.20 115.70 77.35 39.65 24.05 118800 9900 6600 225.06 190.74 163.02 130.68 73.92 51.48 185.46 150.48 117.48 78.54 40.26 24.42 120600 10050 6700 228.47 193.63 165.49 132.66 75.04 52.26 188.27 152.76 119.26 79.73 40.87 24.79 122400 10200 6800 231.88 196.52 167.96 134.64 76.16 53.04 191.08 155.04 121.04 80.92 41.48 25.16 124200 10350 6900 235.29 199.41 170.43 136.62 77.28 53.82 193.89 157.32 122.82 82.11 42.09 25.53 126000 10500 7000 238.70 202.30 172.90 138.60 78.40 54.60 196.70 159.60 124.60 83.30 42.70 25.90 127800 10650 7100 242.11 205.19 175.37 140.58 79.52 55.38 199.51 161.88 126.38 84.49 43.31 26.27 129600 10800 7200 245.52 208.08 177.84 142.56 80.64 56.16 202.32 164.16 128.16 85.68 43.92 26.64 131400 10950 7300 248.93 210.97 180.31 144.54 81.76 56.94 205.13 166.44 129.94 86.87 44.53 27.01 133200 11100 7400 252.34 213.86 182.78 146.52 82.88 57.72 207.94 168.72 131.72 88.06 45.14 27.38 135000 11250 7500 255.75 216.75 185.25 148.50 84.00 58.50 210.75 171.00 133.50 89.25 45.75 27.75
REF #: 2190398
* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement.
Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.
ESC REGION 11 BENEFITS COOPERATIVE Costs below are based on a Monthly payroll deduction
(Employer billing mode is based on 12 Payments per year)
Option 3
43
ESC Region 11 Benefits Co-op
GC-3Limited Benefit Group Cancer Indemnity Insurance (includes Continuation Rider)
THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THIS 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.
APSB-22175(TX)-0914 ESC Region 11 Benefits Co-op44
Benefit Description
Radiation Therapy / Chemotherapy / Immunotherapy Benefit
Hormone Therapy Benefit
Surgical Schedule Benefit
Anesthesia Benefit
Outpatient Hospital or Ambulatory Surgical Center Benefit
Hospital Confinement Benefit
U.S. Government / Charity Hospital / HMO Benefit
Drugs and Medicine Benefit s Inpatient s Outpatient
Blood, Plasma and Platelets Benefit
Transportation and Outpatient Lodging Benefit s Transportation s Lodging
Family Member Transportation and Lodging Benefit s Transportation s Lodging
Bone Marrow / Stem Cell Transplant Benefit
Attending Physician Benefit
Prosthesis Benefit s Surgical Implantation s Hair Prosthesis
Second and Third Surgical Opinion Benefit
Ambulance Benefit s Ground s Air
Extended Care Benefit
Home Health Care Benefit
Hospice Care Benefit
Physical / Speech Therapy Benefit
Dread Disease Benefit
Experimental Treatment Benefit
Inpatient Special Nursing Services Benefit
Waiver of Premium Benefit
Level 12
$1,500 per calendar month of treatment
$50 per treatment, up to 12 per calendar year
$4,800 max per operation; $45 per surgical unit
25% of the amount paid for covered surgery
$600 per day of surgery
$300 per day, 1 - 90 days; $300 per day, 91+ days, in lieu of all other benefits
$300 per day in lieu of most other benefits
$150 per Confinement $50 per prescription, up to $150 per calendar month
$250 per day, up to $12,500 per calendar year
$.50 per mile per round trip.$100.00 per day up to 100 days per calendar year
$.50 per mile per round trip.$100.00 per day up to 100 days per calendar year
Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year
$50 per day of Confinement
$3,000 per device, (includes surgical fee); max. 1 device per site, 2 lifetime max $50 per hair prosthetic; 2 lifetime max.
$300 per diagnosis; additional $300 if third opinion required
$200 per ground trip $2,000 per air trip; up to 2 trips per Hospital Confinement (any combination of ground/ air)
$300 per day
$300 per day
$100 per day, $18,000 lifetime max
$25 per visit, up to 4 visits per calendar month, $1,000 lifetime max
$300 per day, 1 - 90 days of Hospital Confinement
Pays as any non-experimental benefit
$150 per day of Confinement
Premium waived after 90 days of Primary Insured continuous total disability due to Cancer
Level 10
$500 per calendar month of treatment
$50 per treatment, up to 12 per calendar year
$1,600 max per operation; $15 per surgical unit
25% of the amount paid for covered surgery
$200 per day of surgery
$100 per day, 1 - 90 days; $100 per day, 91+ days, in lieu of all other benefits
$100 per day in lieu of most other benefits
$150 per Confinement $50 per prescription, up to $50 per calendar month
$150 per day, up to $7,500 per calendar year
$.50 per mile per round trip.$100.00 per day up to 100 days per calendar year
$.50 per mile per round trip.$100.00 per day up to 100 days per calendar year
Autologous - $500 per calendar year Non-Autologous - $1,500 per calendar year
$30 per day of Confinement
$1,000 per device, (includes surgical fee); max. 1 device per site, 2 lifetime max $50 per hair prosthetic; 2 lifetime max.
$300 per diagnosis; additional $300 if third opinion required
$200 per ground trip $2,000 per air trip; up to 2 trips per Hospital Confinement (any combination of ground/ air)
$100 per day
$100 per day
$50 per day, $9,000 lifetime max
$25 per visit, up to 4 visits per calendar month, $1,000 lifetime max
$100 per day, 1 - 90 days of Hospital Confinement
Pays as any non-experimental benefit
$150 per day of Confinement
Premium waived after 90 days of Primary Insured continuous total disability due to Cancer
Summary of Benefits by Level*
Refer to Benefit Highlights for more complete Benefit Descriptions and limits on the Group Cancer Indemnity Plan. *The premium and amount of benefits provided vary dependent upon the Level selected at time of application.
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Optional Riders
Critical Illness Rider
Hospital Intensive Care Unit Rider
For a Covered Person: s Pays when diagnosed after 30-day Critical Illness Waiting Period with Internal Cancer or Heart Attack/ Stroke depending upon the Critical Illness coverage elected at time of application.s Pays up to the specified Maximum Benefit Amount per Covered Critical Illness, as shown in the certificate policy schedule.s Each benefit is a one time paid benefit.s All Critical Illness benefit amounts reduce by 50% at age 70.
Cancer Benefit$2,500 per Unit;
1 Unit
For a Covered Person: s Confinement must be due to accident or sickness and begin after the effective date of coverage under this rider.s A day is defined as a 24-hour period.s If confined to an ICU for a portion of a day, a pro rata share of the daily benefit will be paid.
Pays $200per day up to 30 days
per confinement in an ICU3 Units
Pays $100in Ambulance expensesper admission in an ICU.
Diagnostic Testing Benefit Rider
Diagnostic Testing Benefit$25 per Unit;
2 Units
For a Covered Person:s Pays an indemnity amount for one medically recognized screening test per calendar year to detect internal Cancer.s Payable without a diagnosis of Cancer.
Heart Attack / Stroke Benefit$2,500 per Unit;
1 Unit
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Radiation Therapy / Chemotherapy / Immunotherapy BenefitPays the indemnity amount when a Covered Person receives treatment and incurs a charge for covered therapy or covered drugs for Radiation Therapy, Chemotherapy, or Immunotherapy as defined in the policy/certificate. We will pay only one Radiation Therapy/Chemotherapy/Immunotherapy benefit per calendar month regardless of the number of treatments received during the month. This benefit does not cover other procedures related to Radiation Therapy/Chemotherapy/Immunotherapy as listed in the policy/certification. Anti-nausea drugs are not covered under this benefit. This benefit does not include any drugs/medicines covered under the Drugs and Medicine Benefit or the Hormone Therapy Benefit.
Hormone Therapy BenefitPays the indemnity amount for hormone therapy treatments as defined in the policy/certificate, prescribed by a Physician. This benefit covers drugs and medicines only and not associated administrative processes. This benefit does not include drugs/medicines covered under the Radiation Therapy/Chemotherapy/Immunotherapy Benefit or the Drugs and Medicine Benefit.
Surgical BenefitPays an indemnity benefit up to the Maximum Per Operation amount shown in the Schedule of Benefits in the policy/certificate when a surgical operation is performed on a Covered Person for covered diagnosed Cancer, Skin Cancer, or reconstructive surgery due to Cancer. Benefits will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount shown in the Schedule of Benefits. Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone marrow surgeries are paid under the Bone Marrow/Stem Cell Transplant Benefit. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis Benefit.
Anesthesia BenefitThe Anesthesia benefit pays 25% of the amount paid for a covered surgery for the services of an anesthesiologist. Services of an anesthesiologist for bone marrow transplants, Skin Cancer, or surgical prosthesis implantation are not covered under this benefit.
Outpatient Hospital or Ambulatory Surgical Center BenefitPays the indemnity amount shown towards the facility fee charges of an Ambulatory Surgical Center or Hospital for an outpatient surgical procedure of a diagnosed Cancer. Surgical procedures for Skin Cancer are not covered under this benefit.
Hospital Confinement BenefitPays the indemnity amount shown for a Covered Person while confined to a Hospital for at least 18 continuous hours for the treatment of a covered Cancer or the treatment of a condition or disease directly caused by Cancer or the treatment of Cancer. When the Covered Person’s Hospital Confinement continues for more than 90 days, this benefit will be paid in lieu of all other benefits payable for the Covered Person during such Hospital Confinement beginning on the 91st day. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.
U.S. Government / Charity Hospital / H.M.O. BenefitIf an itemized list of services is not available because a Covered Person is: confined in a charity Hospital or U.S. Government owned Hospital; or covered under a Health Maintenance Organization (H.M.O.) or a Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person, the Primary Insured may convert benefits to pay the indemnity amount shown. This benefit will be paid in lieu of most benefits under the policy/certificate.
Drugs and Medicines BenefitPays the indemnity amount for anti-nausea and pain medication prescribed by a Physician for a Covered Person for treatment of Cancer, who is also receiving Radiation Therapy / Chemotherapy/Immunotherapy, a covered surgery, or a Bone Marrow/Stem Cell Transplant. This benefit does not cover associated administrative processes. This benefit does not include drugs/medicines covered under the Radiation Therapy/Chemotherapy/Immunotherapy Benefit or the Hormone Therapy Benefit.
Blood, Plasma & Platelets BenefitPays the indemnity amount for blood, plasma and platelets. This does not include any laboratory processes. Colony stimulating factors are not covered under this benefit. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit.
Transportation and Outpatient Lodging BenefitPays for transportation of a Covered Person, who has been diagnosed as having Cancer, to receive covered Radiation Therapy, Chemotherapy, Immunotherapy treatment, Bone Marrow/Stem Cell Transplant, or surgery in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. Such Hospital must be prescribed by a Physician and be the nearest Hospital which offers the specialized treatment. If treatment is received on an outpatient basis, we will also pay the amount shown in the Schedule of Benefits for the Covered Person's lodging in a single room in a motel, hotel or other accommodation acceptable to us while the Covered Person is receiving the specialized treatment. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Travel will be paid at the stated rate shown in the Schedule of Benefits. Benefits will be provided for only one mode of transportation per round trip. If the Covered Person receives treatment while Hospital Confined, benefits for transportation will be paid once per Hospital Confinement. Benefits for lodging will be paid only on those days the Covered Person received outpatient treatment.
Family Member Transportation and Lodging BenefitPays for one adult family member to be near a Covered Person who is receiving covered Radiation Therapy, Chemotherapy, Immunotherapy treatment, Bone Marrow/Stem Cell Transplant, or surgery due to Cancer in a non-local Hospital. Non-local means the Hospital is at least 50 miles away from the Covered Person's residence, using the most direct route. We will pay the amount shown in the Schedule of Benefits for the family member's:(1) lodging in a single room in a motel, hotel or other accommodation acceptable to us; and (2) travel by scheduled bus, plane or train, or by car.Travel will be paid at the stated rate per mile shown in the Schedule of Benefits. If the family member and the Covered Person who is receiving treatment travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging Benefit. Benefits will be provided for only one mode of transportation per round trip. Travel must be within the United States or its Territories. If the Covered Person receives treatment while Hospital Confined, benefits for travel and/or lodging will be paid once per Hospital Confinement. If treatment is received on an outpatient basis, benefits for travel and/or lodging will be paid only on those days the Covered Person received outpatient treatment.
Bone Marrow Benefit / Stem Cell Transplant BenefitPays the indemnity amount when a bone marrow transplant or peripheral blood stem cell transplant is performed on a Covered Person as treatment for a diagnosed Cancer. This benefit will not be paid for the harvest of bone marrow or stem cells from a donor.
This benefit is payable in or out of the Hospital.
Attending Physician BenefitPays the indemnity amount for one Physician’s visit per day when a Covered Person requires the services of a Physician, other than a surgeon while Hospital Confined for the treatment of Cancer.
Policy Benefit Highlights
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Prosthesis Benefit and Hair Prosthesis BenefitPays the indemnity amount for a surgically implanted prosthetic device received due to Cancer that manifested after the 30th day following the Effective Date, provided it was prescribed by a Physician as a direct result of surgery for Cancer. This benefit does not cover prosthetic related supplies. Temporary prosthetic devices used as tissue expanders are covered under the Surgical Benefit. Hair Prosthesis benefit pays the indemnity amount for a Covered Person’s hair prosthesis needed as a direct result of Cancer or the treatment of Cancer.
Second & Third Surgical Opinion BenefitPays the indemnity amount once per diagnosis for a Covered Person’s second surgical opinion and if the second disagrees with the first, we will pay a third opinion, when the attending Physician recommends surgery for the treatment of Cancer. Surgical opinions for reconstructive, Skin Cancer, or prosthesis surgeries are not covered under this benefit.
Ambulance BenefitPays the indemnity amount per trip for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and Hospital confined for at least 18 consecutive hours for treatment of Cancer.
Extended Care Facility BenefitPays the indemnity amount for each day room and board charges are incurred while a Covered Person is confined in an Extended Care Facility due to Cancer at the direction of a Physician that begins within 14 days after a covered Hospital Confinement. Paid for up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement.
Home Health Care BenefitPays the indemnity amount for a Covered Person’s Home Health Care, as described in the policy/certificate, required due to Cancer when prescribed by a Physician in lieu of Hospital Confinement. This benefit does not include physical therapy or speech therapy. This benefit does not include: nutrition counseling; medical social services; medical supplies; prosthesis or orthopedic appliances; rental or purchase of durable medical equipment; drugs or medicines; child care; meals or house-keeping services. This benefit will be paid for up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. If the Covered Person qualifies for coverage under the Hospice Care Benefit, the Hospice Care Benefit will be paid in lieu of this benefit. The caregiver may not be a family member.
Hospice Care BenefitPays the indemnity amount for Hospice Care directed by a licensed Hospice organization, as defined in the policy/certificate, of a Covered Person expected to live six months or less due to Cancer. This benefit does not include: well baby care; volunteer services; meals; housekeeping services; or family support after the death of the Covered Person.
Physical or Speech Therapy BenefitPays the indemnity amount if a Physician advises a Covered Person to seek physical therapy or speech therapy. Physical or speech therapy must be performed by a caregiver licensed in physical or speech therapy and be needed as a result of Cancer or the treatment of Cancer. We will pay for one treatment per day up to four treatments per calendar month per Covered Person for any combination of physical or speech therapy up to a lifetime maximum of $1,000 per person.
Dread Disease BenefitPays the indemnity amount for each period of Hospital Confinement of a Covered Person for treatment of Dread Disease, as defined in the policy/certificate. Benefits for Dread Disease are ONLY provided under this provision of the policy/certificate.
Experimental Treatment BenefitPays benefits for Experimental Treatment, as defined in the policy/certificate, the same as any other non-experimental treatment covered under this policy/certificate. This benefit does not provide coverage for treatments received outside of the United States or its Territories.
Inpatient Special Nursing Services BenefitPays the indemnity amount shown for full-time special nursing care (other than that regularly furnished by a Hospital) while a Covered Person is Hospital Confined for treatment of Cancer. “Full-time” means at least eight consecutive hours during a 24-hour period. Care must be provided by a Nurse, as defined in this policy/certificate; be prescribed by a Physician; and be Medically Necessary for the treatment of Cancer.
Waiver of Premium BenefitIf the Primary Insured becomes disabled due to Cancer and remains so for 90 continuous days, we will pay all premiums due after the 90th day so long as the Primary Insured remains disabled. “Disabled” means the Primary Insured’s inability because of Cancer: to work at any job for which (s)he is qualified by education, training, or experience; not working at any job for pay or benefits; and are under the care of a Physician for the treatment of Cancer. This policy/certificate must be in force at the time disability begins and the Primary Insured must be under age 65.
Continuation RiderContinuation Coverage is continued when the Insured (You) cease employment with the employer through whom You originally became insured under the Policy. You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our home office. Premiums must be paid within thirty-one (31) days after employment with your employer terminates. Premium rates required under this Continuation provision will be the same rates as those charged under the Employer’s Policy as if You had continued employment. We will bill You for these premiums after You notify Us to continue this coverage. Coverage will continue until the earlier of: (1) the Policy under which You originally became insured ends; or (2) You stop paying premiums under this option (subject to the terms of the Grace Period).
ConversionIf the Employer’s Policy is terminated, this Certificate will terminate. Upon termination of the Employer’s Policy, the employee (You) will be entitled to convert to an individual policy of insurance issued by Us without evidence of insurability provided the required premiums have been paid on your behalf and You notified Us in writing within thirty-one (31) days of the Employer’s Policy termination. Premiums for the individual policy of insurance will be figured from the premium rate table in effect on the date of conversion.
Subject to the terms of this provision, a covered child who ceases to be eligible may convert to an individual policy of insurance and a covered spouse who ceases to be eligible for coverage because of divorce or annulment may convert to an individual policy.
Terms of this provision include: (1) Application for the individual policy and payment of the first premium must be made within 60 days after coverage ceases under the Policy/Certificate. Premiums will be figured from the premium rate table in effect on the date of conversion. (2) The individual policy will be issued without proof of insurability. It will provide benefits that most nearly approximate those of the Policy/Certificate. (3) The individual policy will take effect the day after coverage ceases under the Policy/Certificate. However, no benefits will be payable under the individual policy for any loss for which benefits are payable under the Policy/Certificate. (4) The Pre-Existing Condition Limitation and Time Limit on Certain Defenses provisions for the individual policy will be figured from the Covered Person's Effective Date of coverage under the Policy/Certificate. (5) Any benefit maximums will be figured from the Effective Date of the Policy/Certificate.
This rider is subject to all the provisions of the Policy and Certificate to which it is attached that are not in conflict with this rider.
See the policy/certificate for more information regarding the benefits listed above. 48
EligibilityThis policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage.
If You are working either under contract to or as a Full Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us.
Cancer means a disease which is manifested by autonomous growth (malignancy) in which there is uncontrolled growth, function, or spread (local or distant) of cells in any part of the body. This includes Cancer in situ and malignant tumors. It does not include other conditions which may be considered precancerous or having malignant potential such as: leukoplakia; hyperplasia; polycythemia; actinic keratosis; myelodysplastic and non-malignant myeloproliferative disorders; aplastic anemia; atypia; non-malignant monoclonal gamopathy; carcinoid; or pre-malignant lesions, benign tumors or polyps.
Base PolicyAll diagnosis of Cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer.
No benefits are payable for any Covered Person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A Pre-Existing Condition is a Specified Disease for which, within 12 months prior to the Covered Person's Effective Date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any Covered Person has a Specified Disease diagnosed before the end of the 30-day period immediately following the Covered Person’s Effective Date, coverage for that person will apply only to loss that is incurred after one year from the Effective Date of such person’s coverage. If any Covered Person is diagnosed as having a Specified Disease during the 30-day period immediately following the Effective Date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the Schedule of Benefits in the policy/certificate.
Diagnostic Testing Benefit RiderWe will pay the indemnity amount for one generally medically recognized internal Cancer screening test per Covered Person per Calendar Year. Screening test include, but are not limited to: mammogram; breast ultrasound; breast thermography; breast cancer blood test (CA 15-3); colon cancer blood test (CEA); prostate-specific antigen blood test (PSA); flexible sigmoidoscopy; colonoscopy; virtual colonoscopy; ovarian cancer blood test (CA-125); pap smear (lab test required); chest x-ray; hemocult stool specimen; serum protein electrophoresis (blood test for myeloma); Thin Prep Pap test. Screening tests payable under this benefit will ONLY be paid under this benefit. Benefits will only be paid for tests performed after the 30-day period following the Covered Person’s effective date of coverage.
Critical Illness RiderBenefits will only be paid for a Covered Critical Illness as shown on the Policy/Certificate Schedule page in the policy. No benefits will be provided for any loss caused by or resulting from: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; or alcoholism or drug addiction; or any act of war, declared or undeclared, or any act related to war; or military service for any country at war; or a Pre-Existing Condition; or a Covered Critical Illness when the Date of Diagnosis occurs during the Waiting Period; or participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; or participation in, or attempting to participate in a felony, riot or insurrection (A felony is as defined by the law of the jurisdiction in which the activity takes place). Internal Cancer does not include: other conditions that may be considered pre-cancerous or having malignant potential such as: acquired immune deficiency syndrome (AIDS); or actinic keratosis; or myelodysplastic and non-malignant myeloproliferative disorders; or aplastic anemia; or atypia; or non-malignant monoclonal gamopathy; or Leukoplakia; or Hyperplasia; or Carcinoid; or Polycythemia; or carcinoma in situ or any skin cancer other than invasive malignant melanoma into the dermis or deeper. For a Pre-Existing Condition no benefits are payable. Pre-Existing Condition, as used in this rider means any sickness or condition for which prior to the Effective Date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment.
Hospital Intensive Care Unit RiderNo benefits will be provided during the first two years of this rider for Hospital Intensive Care Unit confinement caused by any heart condition when any heart condition was diagnosed or treated prior to the 30th day following the Covered Person’s Effective Date of this rider. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the Effective Date. No benefits will be provided if the loss results from: attempted suicide, whether sane or insane; or intentional self-injury; or alcoholism or drug addiction; or any act of war, declared or undeclared, or any act related to war; or military service for any country at war. No benefits will be paid for confinements in units such as: Surgical Recovery Rooms, Progressive Care, Burn Units, Intermediate Care, Private Monitored Rooms, Observation Units, Telemetry Units or Psychiatric Units not involving intensive medical care; or other facilities which do not meet the standards for Intensive Care Unit as defined in the Rider. For a newborn child born within the ten-month period following the effective date of this rider, no benefits will be provided for Hospital Intensive Care Unit Confinement that begins within the first 30 days following the birth of such child.
Limitations and Exclusions
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Conditionally RenewableThis policy/certificate is conditionally renewable. This means that We have the right to terminate your policy/certificate on any premium due date after the first Policyholder’s Anniversary Date. We must give the Policyholder at least 60 days written notice prior to cancellation. We cannot cancel Your coverage because of a change in Your age or health. We can, however, change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums.
Termination of Coverage Your Insurance coverage will end on the earliest of these dates: (a) the date You no longer qualify as an Insured; (b) the last day of the period for which a premium has been paid, subject to the Grace Period; (c) the date the Policy terminates (See Conversion provision); (d) the date You retire; (e) the date You cease employment, or terminate Your contract with the employer through whom You originally became insured under the Policy (See Conversion provision); or (f ) the date We receive Your written request for termination. Termination of Dependent(s) Insurance coverage on Your Dependent(s) will end on the earliest of these dates: (a) the date the coverage under the Certificate terminates; (b) the date the Dependent no longer meets the definition of Dependent, as defined in the Policy/Certificate (See Conversion provision); (c) the date We receive Your written request for termination. Termination of Rider Coverage This rider terminates: (a) when Your coverage terminates under the Policy/Certificate to which this Rider is attached; or, (b) when any premium for this rider is not paid before the end of the Grace Period; or, (c) when You give Us a written request to do so. Coverage on a Dependent terminates under this rider when such person ceases to meet the definition of Dependent, as defined in the Policy.
Limitations and Exclusions continued
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Level 10 Level 12
Individual 1 Parent 2 Parent Individual 1 Parent 2 Parent
$9.80 $13.30 $16.80 $25.90 $35.10 $44.40
GC-3 Group Cancer Indemnity Insurance
Critical Illness RiderRates based on 1 unit (1 unit = $2,500) **If both Cancer and Heart/Stroke coverage is applied for, an equal number of units must be purchased.
Diagnostic Testing Benefit RiderRates based on 2 units (2 units = $50)
Group Cancer Monthly Premiums By Level* (Composite Rates)
Optional Benefit Riders’ Monthly Premiums* (Composite Rates)
Hospital Intensive Care Unit RiderRates based on 3 units (3 units = $600)
ICU
Individual 1 Parent 2 Parent
$3.30 $4.50 $6.90
Diagnostic
Individual 1 Parent 2 Parent
$2.20 $3.40 $4.40
Cancer & Heart / Stroke Only**
Individual 1 Parent 2 Parent
$4.30 $6.10 $7.80
This is a brief description of the coverage. For actual benefits and other provisions, please refer to the policy and rider(s). This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC-3 series | Texas | Limited Benefit Group Cancer Indemnity Insurance | Employee Brochure | (04/14) | MGM/FBS | ESC Region 11 Benefits Co-op-13060
Underwritten by:
2305 Lakeland Drive | Flowood, MS | 39232ampublic.com | 800.256.8606
*The premium and amount of benefits provided vary dependent upon the Level selected at time of application.
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This summary is for illustrative purposes only and does not constitute a contract. The full terms and conditions of the coverage you select will be contained in the policies provided to the ESC Region XI Benefits Cooperative. If there is any discrepancy between this benefit description and the policy the terms of the policy will govern.
ESC Region 11 Benefits Cooperative EMPLOYER PAID LIFE AND AD&D BENEFITS AT A GLANCE
Unum is your Life Insurance Carrier. Your benefits are outlined below.
Your Basic and Voluntary Life Insurance automatically includes:
BASIC GROUP TERM LIFE AND AD&DAll full time active employees working at least 17.5 hours each week are eligible for Basic Group Life and Accidental Death and
Dismemberment (AD&D). Life and AD&D benefits reduce to 65% at age 70; and 50% at age 75.
Coverage is equal
to the following
Option I Option Based on Employer Schools $10,000
Option 2 Option Based on Employer Schools $30,000
Option 3 Option Based on Employer Schools $40,000
Your Basic Group Term Life Insurance automatically includes:
Life Planning Financial & Legal Resources: This personalized financial counseling service provides expert, objective
financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the
death or terminal illness of your covered spouse.
Work/Life Balance Employee Assistance Program: Work‐life balance is a comprehensive resource providing access to
professional assistance for a wide range of personal and work‐related issues.
Worldwide Emergency Travel Assistance Services: Whether your travel is for business or pleasure, our worldwide
emergency travel assistance program is there to help you when an unexpected emergency occurs.
Waiver of Premium: Life insurance premiums will be waived for insured employees who become disabled prior to a
specified age, and who remain disabled during an elimination period.
Accelerated Death Benefit: Pays a portion of the insured employee’s or dependent’s Life benefit in the event the insured
employee or dependent becomes terminally ill and the employee’s or dependent’s life expectancy has been reduced to less
than 12 months. The employee’s or dependent’s death benefit will be reduced by the Accelerated Life Benefit paid.
Portability Privilege: Allows an insured employee and their dependents to elect portable coverage at group rates, if the
employee terminates employment, reduces hours or retires from the employer. Employees and their dependents are not
eligible for portable coverage if they have an injury or sickness, under the terms of this plan, that has a material effect on
life expectancy.
Conversion Privilege: When an insured employee’s group coverage ends, employees and their dependents may convert
their coverage to individual life policies without providing evidence of insurability.
See contract for additional plan and coverage details.
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Term Life Insurance and AD&D
Coverage Highlights
ADR1879-2001
ESC Region 11 Benefits Cooperative
Please read carefully the following description of your Unum Term Life and AD&D insurance plan.
Your Plan
Eligibility All employees working at least 17.5 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 26.
Coverage Amounts
Your Term Life coverage options are:
Employee: Up to 7 times salary in increments of $10,000. Not to exceed $500,000.
Spouse: Up to 100% of employee amount in increments of $10,000. Not to exceed $500,000. Benefits will be paid to the employee.
Child: Two options available. Option 1: $5,000 or Option 2: $10,000 Not to exceed 100% of employee amount, to a maximum of $10,000.
Child age is 6 months to 26 years. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee.
In order to purchase Life coverage for your spouse and/or child, you must purchase Life coverage for yourself.
Your AD&D coverage options are:
Employee: Up to 7 times salary in increments of $10,000. Not to exceed $500,000. You may purchase AD&D coverage for yourself regardless of whether you purchase Life coverage.
Employee and Family: Spouse: 50% of employee amount, not to exceed $250,000. Benefits will be paid to the employee. Child: 10% of employee amount, not to exceed $10,000.
Child age is 6 months to 26 years. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee.
In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself.
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Term Life Insurance and AD&D Coverage Highlights (Continued)
AD&D Benefit Schedule: The full benefit amount is paid for loss of: Life Both hands or both feet or sight of both eyes One hand and one foot One hand and the sight of one eye One foot and the sight of one eye Speech and hearing
Other losses may be covered as well. Please see your Plan Administrator.
Coverage amount(s) will reduce according to the following schedule:
Age: Insurance Amount Reduces to: 70 65% of original amount 75 50% of original amount
Coverage may not be increased after a reduction.
Guarantee Issue
Current Employees: If you and your eligible dependents enroll on or before the enrollment deadline, you may apply for any amount of Life insurance coverage up to $230,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll on or before the enrollment deadline, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of Life insurance coverage. AD&D coverage does not require evidence of insurability.
If you and your eligible dependents enroll on or before the enrollment deadline, and later wish to increase your Life insurance coverage, you may increase your coverage with evidence of insurability at anytime during the year. However, you may wait until the next annual enrollment and only coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability.
New Hires: If you and your eligible dependents enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance coverage up to $230,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. AD&D coverage does not require evidence of insurability.
If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your Life insurance coverage, with evidence of insurability, at anytime during the year. However, you may wait until the next annual enrollment and only Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability.
Please see your Plan Administrator for your eligibility date.
Insurance Age Your rate is based on your age as of policy anniversary.
58
Term Life Insurance and AD&D Coverage Highlights (Continued)
Additional Benefits
Life Planning Financial & Legal Resources
This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. The financial consultants are master level consultants. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security. At no time will the consultants offer or sell any product or service.
Portability/Conversion
If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy.
Accelerated Benefit If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 50% of your life insurance amount up to $750,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies). This feature also applies to your covered dependents.
Waiver of Premium If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability.
Retained Asset Account Benefits of $10,000 or more are paid through the Unum Retained Asset Account. This interest bearing account will be established in the beneficiary's name. He or she can then write a check for the full amount or for $250 or more, as needed.
Additional AD&D Benefits Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.) Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.
Limitations/Exclusions/ Termination of Coverage
Suicide Exclusion Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage.
No increased or additional benefits will be payable for deaths caused by suicide occurring within 24 months after the day such increased or additional insurance is effective.
AD&D Benefit Exclusions AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from:
Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders;
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Term Life Insurance and AD&D Coverage Highlights (Continued)
Suicide, self-destruction while sane, intentionally self-inflicted injury while sane, or self-inflicted injury while insane;
War, declared or undeclared, or any act of war;
Active participation in a riot;
Attempt to commit or commission of a crime;
The voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol;
Intoxication. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.)
Termination of Coverage Your coverage and your dependents’ coverage under the Summary of Benefits ends on the earliest of:
The date the policy or plan is cancelled;
The date you no longer are in an eligible group;
The date your eligible group is no longer covered;
The last day of the period for which you made any required contributions;
The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage;
For dependent’s coverage, the date of your death.
In addition, coverage for any one dependent will end on the earliest of:
The date your coverage under a plan ends;
The date your dependent ceases to be an eligible dependent;
For a spouse, the date of divorce or annulment.
Unum will provide coverage for a payable claim which occurs while you and your dependents are covered under the policy or plan.
Next Steps
How to Apply Current employees: To apply for coverage, complete your enrollment form by the enrollment deadline.
New Hires: To apply for coverage, complete your enrollment form within 31 days of your eligibility date.
All employees: If you apply for coverage after your effective date, or if you choose coverage over the guarantee issue amount, you will need to complete a medical questionnaire which you can get from your Plan Administrator. You may also be required to take certain medical tests at Unum’s expense.
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Term Life Insurance and AD&D Coverage Highlights (Continued)
Effective Date of Coverage Please see your Plan Administrator for your effective date.
Delayed Effective Date of Coverage
Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.
Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth.
“Totally disabled” means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life threatening condition.
Changes to Coverage Each year you and your spouse will be given the opportunity to change your Life coverage and AD&D coverage. You and your spouse may purchase additional Life coverage up to the Guarantee Issue amounts without evidence of insurability if you are already enrolled in the plan. Life coverage over the Guarantee Issue amounts will be medically underwritten and will require evidence of insurability and approval by Unum’s Medical Underwriters. The suicide exclusion will apply to any increase in coverage. AD&D coverage does not require evidence of insurability for increase amounts.
Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al.
Life Planning is provided by Ceridian Incorporated. The services are subject to availability and may be withdrawn by Unum without prior notice. Underwritten by: Unum Life Insurance Company of America, 2211 Congress Street, Portland, Maine 04122, www.unum.com Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. ©2007 Unum Group. All rights reserved.
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EMPLOYEE
$30,000 $40,000 $50,000 $70,000Age Band0-24 $1.35 $1.80 $2.25 $3.1525-29 $1.35 $1.80 $2.25 $3.1530-34 $1.80 $2.40 $3.00 $4.2035-39 $2.10 $2.80 $3.50 $4.9040-44 $2.40 $3.20 $4.00 $5.6045-49 $3.60 $4.80 $6.00 $8.4050-54 $6.00 $8.00 $10.00 $14.0055-59 $9.90 $13.20 $16.50 $23.1060-64 $15.30 $20.40 $25.50 $35.7065-69 $28.50 $38.00 $47.50 $66.5070-74 $46.50 $62.00 $77.50 $108.5075+ $61.80 $82.40 $103.00 $144.20
EMPLOYEE ONLY ACCIDENTAL DEATH & DISMEMBERMENT RATES:0-79+ $1.20 $1.60 $2.00 $6.00
SPOUSE$30,000 $40,000 $50,000 $70,000
Age Band
0-24 $1.35 $1.80 $2.25 $3.15
25-29 $1.35 $1.80 $2.25 $3.1530-34 $1.80 $2.40 $3.00 $4.2035-39 $2.10 $2.80 $3.50 $4.9040-44 $2.40 $3.20 $4.00 $5.6045-49 $3.60 $4.80 $6.00 $8.4050-54 $6.00 $8.00 $10.00 $14.0055-59 $9.90 $13.20 $16.50 $23.1060-64 $15.30 $20.40 $25.50 $35.7065-69 $28.50 $38.00 $47.50 $66.5070-74 $46.50 $62.00 $77.50 $108.5075+ $61.80 $82.40 $103.00 $144.20
$5,000 $10,000$0.90 $1.80
*NOTE: The premium paid for child coverage is based on the cost of coverage for one child, regardless of how many children you have.
FAMILY ACCIDENTAL DEATH & DISMEMBERMENT RATES:
$10,000 $30,000 $40,000 $50,000 $70,000$0.70 $1.40 $2.10 $2.80 $3.50 $4.90 $7.00 $9.10 $10.50
X =# of 10,000 units
* AGE = AGE ON POLICY ANNIVERSARY
NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING. THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000 (NOT TO EXCEED 5 TIMES YOUR ANNUAL SALARY). TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY COMPLETE THE FOLLOWING.
Your age cost per 10,000 unit MONTHLY COST
$50,000 IS THE MAXIMUM THAT MAY BE ISSUED WITHOUT ANSWERING HEALTH QUESTIONS
CHILD(REN)*
$20,000 $100,000 $130,000 $150,000
$15.50 $31.00 $155.00 $201.50 $232.50$20.60 $41.20 $206.00 $267.80 $309.00
$5.10 $10.20 $51.00 $66.30 $76.50$9.50 $19.00 $95.00 $123.50 $142.50
$2.00 $4.00 $20.00 $26.00 $30.00$3.30 $6.60 $33.00 $42.90 $49.50
$0.80 $1.60 $8.00 $10.40 $12.00$1.20 $2.40 $12.00 $15.60 $18.00
$0.60 $1.20 $6.00 $7.80 $9.00$0.70 $1.40 $7.00 $9.10 $10.50
$0.45 $0.90 $4.50 $5.85 $6.75
$0.45 $0.90 $4.50 $5.85 $6.75
$0.40 $0.80 $2.80 $4.00 $5.20
$10,000 $20,000 $100,000 $130,000 $150,000
$20.60 $41.20 $206.00 $267.80 $309.00
$230,000 IS THE MAXIMUM THAT MAY BE ISSUED WITHOUT ANSWERING HEALTH QUESTIONS
$9.50 $19.00 $95.00 $123.50 $142.50$15.50 $31.00 $155.00 $201.50 $232.50
$3.30 $6.60 $33.00 $42.90 $49.50$5.10 $10.20 $51.00 $66.30 $76.50
$1.20 $2.40 $12.00 $15.60 $18.00$2.00 $4.00 $20.00 $26.00 $30.00
$0.70 $1.40 $7.00 $9.10 $10.50$0.80 $1.60 $8.00 $10.40 $12.00
$0.45 $0.90 $4.50 $5.85 $6.75$0.60 $1.20 $6.00 $7.80 $9.00
$0.45 $0.90 $4.50 $5.85 $6.75
UNUM CORPORATION LIFESTYLE LIFE RATES ESC REGION 11 BENEFITS COOPERATIVE
Monthly Payroll Deduction
$10,000 $20,000 $100,000 $130,000 $150,000
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© 2014 ID Watchdog, Inc. All Rights Reserved.
EMPLOYEE BENEFIT EXPLANATION
Would you know if someone was out there pretending to be you?More than 12 Million identities were stolen last year. Most victims only discover they have a problem when they are denied credit, denied employment, contacted by police or receive unknown bills.
Why Choose Identity Theft Protection?Identity Theft Devastates Victims FinanciallyThe average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses trying to resolve their case.
Repairing the Damage Caused by Identity Theft is Frustrating and Time-ConsumingThe average victim spends 330 hours repairing the damage from identity theft - the equivalent of working a full-time job for more than two months.
The Impact of Identity Theft Follows Victims for Years50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft.
12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.
How Are Stolen Identities Used?» To obtain medical care
» Provide false information to police
» To register for government benefits such as unemployment or welfare programs
» For gaining legal employment without tax liability
» To open credit cards or take out loans
My Social Security Number was stolen and used to purchase a car, open a bank account and even start a business.
ID Watchdog discovered the fraudulent activity and restored my identity and my credit.
They’re amazing!”- Regina Grahn
Identity Theft Victim
“
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© 2014 ID Watchdog, Inc. All Rights Reserved.
LIFELOCK BASIC
LIFELOCK ULTIMATE
IDENTITY GUARD
INFO ARMOUR
IDW PLUS
IDW PLATINUM
Basic Identity Monitoring
Advanced Identity Monitoring
Alternative Monitoring
Zero Hour Identity Monitoring
Cyber Monitoring
Credit Report Monitoring
Credit Reports & Scores
Lost Wallet
Full-Service Identity Restoration
NPI Monitoring
INDIVIDUAL PLAN $7.95/mo $11.95/mo
FAMILY PLAN $14.95/mo $22.95/mo
TRUE IDENTITY PROTECTIONTM
Basic Identity Monitoring: Standard monthly scans of public records databases searching for new information associated with your Social Security Number.
Advanced Identity Monitoring: Advanced scans of the National Change of Address (NCOA) database identifies new addresses associ-ated with your personal information.
Alternative Monitoring: Identity thieves actions are not always immediately detected through mainstream credit and identity monitoring. Today we scan Non-Credit Payday loan databases which provide high-interest, quick cash transactions and require minimal personal information to obtain. We are expanding our fraud detection network to include monitoring Auto Pawn, Buy-Here- Pay Here auto dealers and Rent-To-Own store transactions. This is the most comprehensive alternative credit monitoring in the ID theft protection industry.
Proactive Zero Hour Identity Monitoring: Continuous monitoring from daily scanning of billions of transactions and data points will provide an early warning alerting customers of high risk transactions. Because this system is monitoring in real time you will be able to detect potential fraud as it is happening or immediately after it has happened- at the source- so that our dedicated team can help you stop it in its tracks and prevent the damage that can occur with identity theft.
Cyber Monitoring: Scans social networking sites, hacker forums, underground websites and other illicit online sources that buy, sell, and trade personal information including (but not limited to) credit card numbers, password, and SSN.
Credit Report Monitoring: Monitors your credit and notifies you when changes such as new accounts, delinquent accounts and other credit-related information is recorded. Plus plan is single-bureau credit monitoring and Platinum plan is tri-bureau monitoring.
Credit Reports & Scores (Platinum Plan Only): Access to your credit reports and scores from the three primary credit reporting agencies; Equifax, Experian and TransUnion.
EXTENDED IDENTITY PROTECTIONLost Wallet: Online safe box securely stores credit card, driver license info and more. Includes cancellation and request for new credit cards in the event your wallet or purse is stolen.
Full-Service Identity Restoration: A dedicated team of trained in-house Certified Identity Theft Resolution Specialists (CITRS) who work on your behalf to restore your identity by addressing record-keeping and reporting agencies, removing erroneous and fraudulent records that appear in your name.
ID Watchdog has a flawless record in restoring victim’s identities- and to date we have never failed to completely restore an identity. A benefit of our concierge level service is few costs associated with identity restoration. However, we know peace of mind is important. All our ID Protection Plans include a $1,000,000 expense reimbursement insurance* to cover those rare instances when expenses may arise during a restoration.
NPI Monitoring: Monitors National Provider Identifiers (NPI) for healthcare professionals.
* Maximum $1 Million reimbursement insurance under a Master Insurance Policy underwritten by American International Group Inc. Please reference ID Watchdog benefits website for claim submission instructions and policy details regarding applicable terms, conditions, and exclusions.
How ID Watchdog Compares to Similar Services ...
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Call us at (888) 365-1663 or visit us at consultmdlive.com
Who are our providers? Are children eligible?
Our providers practice primary care,pediatrics, family and emergency medicine, and have incorporated MDLIVE into their practice to provide convenient access to qualitycare.
Yes. MDLIVE has local pediatricianson-call 24/7/365.However, a parent or guardian must be present during registration and any consultations involvingminors.
24/7/365 on-demand access toaffordable, quality healthcare.Anytime, Anywhere.
MDLIVE offers 24/7/365 on-demand access to anational network of board-certified doctors andpediatricians that can diagnose, recommendtreatment, and prescribe medication. Getthe care you need, when you need it.
What can be treated?
AllergiesAsthmaBronchitisCold and FluEar InfectionsJoint Aches and PainRespiratory InfectionSinus ProblemsAnd More!
Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113
When should I use MDLIVE?If you’re considering the ER or urgent care for a non-emergencymedical issueYour primary care physician is not availableAt home, traveling, or at work24/7/365, even holidays!
Pediatric Care related to:
Cold & FluConstipationEar InfectionFeverNausea & VomitingPink EyeAnd More!
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