2021-2022 E Ser - MGM Benefits Group
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2021-2022
Employee Bene it
Services Group
®
Phone: (830) 606-5100
www.mybenefitshub.com/palestineisd
Enrollment Instructions for THEbenefitsHUB
Site Access: To access your employer online enrollment site,
THEbenefitsHUB, you can login to the following website
www.mybenefitshub.com/palestineisd
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 SSN:
Example: Employee Name - Robert Smith, SS# 123-45-6789
User Name: smithr6789
Default Password: Complete Last Name (Excluding Punctuation) follow by the last
four (4) digits for your SSN
Password Reset: Employees will be prompted to update the password once you enter
into the site.
245 Landa Street
New Braunfels,Texas 78130
Phone: (830) 606-5100
2021-2022
2021-2022 OPEN ENROLLMENT INFORMATION
The 2021-2022 Section 125 Cafeteria Plan year begins 09/01/2021 and ends 08/31/2022.
All benefits elected during the annual open enrollment will be effective 09/01/2021.
Know Your Benefits! Below is a summary of benefits offered through
PISD.
Medical Transport - MASA Provides Emergency Transportation for ground, emergency air, and non-emergency hospital to
hospital transportation anywhere in the US/Canada.
Employee Assistance Program - Employee Assistant Program that provides support, guidance, and resources. A helping
hand when you need it. *Palestine ISD provides all eligible employees at no cost.
TeleMedicine - 1.800MD, provides access to physicians for non-emergency treatment/prescriptions. For questions, please
contact 1.800MD directly at 1-800-530-8666
Gap Plan - A low cost program designed to help you pay for covered out-of-pocket expenses you may incur
while you are either confined in a hospital or being treated as an outpatient for an injury or illness.
Critical Illness UNUM - no Evidence of Insurability required, guaranteed issue.
Standard Disability - Plan includes long term disability coverage. Plan is designed to protect up to 66 2/3% of your gross
PISD income.
Texas Life Permanent Life (* Rate Increase)- Portable, permanent life insurance available for employees, their spouses, and
dependents. Employees can keep the coverage upon termination or retirement from PISD.
UNUM Group Life - Group term life that ends when you terminate employment with PISD. Coverage is also available for
spouses and dependent children.
Colonial Life Cancer - Pays benefits for internal cancer diagnosis.
MetLife Dental - Coverage for preventative, basic, major, and orthodontia services.
Superior Vision - Plan includes coverage for eye exams, materials (such as frames and lenses). This plan has a list of defined
network providers. For more information, including a list of providers, visit
www.superiorvision.com.
Metlife Accident - Pays benefits for off-the-job accidents and related treatments. Includes a physical/wellness exam
reimbursement.
NBS Flexible Spending - Make sure to spend/claim the money in your current reimbursement account by 8/31/2021.
Visit fsa.nbsbenefits.com to check account balances or request information.
HSA Bank - Participants in the TRS-ActiveCare HD health plan are eligible to contribute to a health savings
account.
ENROLLMENT FAQ�
INTRODUCTION MID-YEAR CHANGES
Providing great benefit choices to you and your family is just The benefits you choose will remain in effect throughout the
one of the many ways PISD looks after the health and finan- plan year (from September 1 - August 31). You may only add
cial welfare of the people who make our district work so well. or cancel coverage during the year if you have a qualifying
Our goal at PISD is to provide you with an array of benefit change in the family or employment status that causes you to
options that will meet your personal needs as part of your total gain or lose eligibility for benefits. Qualifying changes may
compensation and rewards. include:
• A change in your legal marital status
HOW DO I ENROLL? • A change in your number of dependents as a result of birth,
Visit www.mybenefitshub.com/palestineisd adoption, legal custody, or if your dependent child satisfies
or ceases to satisfy eligibility requirements for coverage, or
USERNAME: Enter the first 6 letters of your last name,
the death of a dependent child or spouse
followed by the first letter of your first name, and then the
• A change in employment status for you or your spouse loss or
last 4 digits of your SSN. (EX: John Sanderson SSN: xxx-
gain of eligibility for other insurance (including
xx-1234 USERNAME: sanderj1234)
CHIP & Medicaid)
PASSWORD: Complete last name (excluding any
special characters or spaces) followed by the last 4 digits of You must notify the Palestine ISD payroll office of the
your SSN. (Ex: sanderson1234) requested change within 30 calendar days of the change in
status. There are no exceptions to this rule.
WHO IS ELIGIBLE?
• You are eligible to enroll in the PISD Benefits Program if WHEN WILL I RECEIVE ID CARDS?
you are a regular employee working at least 15 hours per Everyone enrolled in Medical will receive a new Medical
week in a permanent position. Card. Enrolled participants will receive HSA and FSA cards
• All other employees, to include substitutes, who work less prior to the effective date of the new coverage. For most
than 15 hours per week, are eligible to enroll in medical plans, you can login to the carrier website and print a
insurance at full cost. temporary ID card or give your provider the insurance
company’s phone number to call and verify your coverage if
WHO IS AN ELIGIBLE DEPENDENT? you do not have an ID card at the time of service.
• Your legal spouse
• Children under the age of 26, yours OR your spouse’s
WHO DO I CONTACT WITH QUESTIONS?
• Dependent children of any age who are disabled
For questions, you can contact your PISD Benefits
• Children under your legal guardianship
Department
When adding dependents for the first time, please provide
date of birth, gender and social security number.
NEW HIRE ENROLLMENT
Online benefit enrollment must be completed within 30 days
Gemma Funai
Office: 903-731-8048
Email: Gfunai@palestineschools.org
Marlene Freeman
@
of your active at work date. Elected benefits will take effect
Office: 830-606-5100
on the 1st of the following month. Email: Mfreeman@usebsg.com
2021-2022
MORE IMPORTANT INFORMATION
Covering Dependents?
If you cover dependents on any of your coverages through PISD you must provide the dependents name, date of
birth, and social security number. You must have all of this information before dependents can be added to the
system.
Making Changes During the Year
Choose your benefits carefully. Several of the employee benefits plan contributions are made on a pre-tax basis and
per IRS regulations, contribution amounts cannot be changed unless you experience a qualified life event.
Qualifying life events include:
• Marriage, divorce, legal separation;
• Death of spouse or dependent;
• Birth or adoption of a child;
• Changes in employment for spouse or dependents;
• Coverage changes;
You must submit your benefit change requests and include required documentation within 30 days of the event.
Also note that per the IRS, only changes consistent with the life event are allowed.
New Employees
New employees must enroll within 30 days of their start date. If employees fail to enroll within 30 days, all
benefits will be waived. Except for health insurance, plans will be effective on the first of the month following the
date of start. Health Insurance can be effective the date of start or the first month following date of start. Please be
aware that if you choose date of start as effective date for health insurance, you will be charged for the entire
month.
Very Important
Please carefully review your paycheck(s) to ensure all deductions are correct. If you find a discrepancy in your
paycheck, please contact Gemma Funai immediately at 903-731-8048. Discrepancies must be identified within the
first 30 days from the effective date of the policy to be considered.
Benefit Related Documents
For contact information, claim forms, benefits guides, and more, please visit palestineschools.org.
1
2021-2022
TABLE OF CONTENTS
CONTACT INFORMATION
MEDICAL TRS
1-866-355-5999 www.BCBStx.com/trsactivecare
PAGES
TELE-MEDICINE 1-800 MD
4-7 1-800-530-8666 www.1800MD.com
8-9 MEDICAL TRANSPORTATION MASA
1-800-423-3226 www.masamts.com
10-11
12-14 ACCIDENT Metlife
1-800-438-6388 www.metlife.com
15-20
CRITICAL ILLNESS UNUM
1-866-679-3054 www.unum.com
21-28
29-30 GAP INSURANCE Benefit Connection
1-800-767-6811 www.specialinc.com
CANCER Colonial Life
1-800-325-4368 www.coloniallife.com
2
2021-2022
TABLE OF CONTENTS
PAGES DISABILITY& The Standard
EAP 1-800-368-1135 www.standard.com
DENTAL MetLife
31-38 1-800-942-0854 www.metlife.com
39-42 VISION Superior Vision
1-800-879-6901 www.superiorvision.com
43
44-49 GROUP & VOLUTARY LIFE UNUM
1-866-679-3054 www.unum.com
50-54
PERMANENT LIFE TEXAS LIFE
55-56 1-800-283-9233 www.texaslife.com
57-60 HEALTH SAVINGS HSA
1-800-357-6246 www.HSAbank.com
61
FLEXIBLE SPENDING NBS
1-800-274-0503 www.nbsbenefits.com
403B RETIREMENT The OMNI Group
1-877-554-6664 www.omni403b.com
*THIS BOOKLET IS FOR INFORMATIONAL PURPOSES ONLY AND HIGHLIGHTS SOME FEATURES OF THE DIFFERENT
POLICIES AND RIDERS BUT IS NOT THE INSURANCE CONTRACT. PLEASE REFER TO THE GROUP MASTER
APPLICATION FOR FULL DISCLOSURE OF BENEFITS.*
3
What’s New and What’s Changing Effective: Sept. 1, 2021
This year, we have the same popular plan features that make TRS-ActiveCare plans standout, including broad
networks, low copays for primary care and TRS Virtual Health, and specialty drug coverage.
2020-21 New 2021-22 Change in Dollar
Key Plan Changes
Total Premium Total Premium Amount
Employee Only $386 $417 $31
No benefits changes!
TRS-ActiveCare Employee and Spouse $1,089 $1,176 $87 This plan still has the lowest monthly costs and copays.
Primary Your Primary Care Provider copay is $30 and TRS Virtual
Employee and Children $695 $751 $56 Health is $0.
Employee and Family $1,301 $1,405 $104
Employee Only $397 $429 $32 • In-network deductible rose by $200 for individuals and $400 for families
• In-network coinsurance rate rose from 20% to 30%
Employee and Spouse $1,120 $1,209 $89 • Out of network coinsurance rate rose from 40% to 50%
TRS-ActiveCare HD • In-network maximum out-of-pocket rose by $100 for individuals and
Employee and Children $715 $772 $57 $200 for families
*All changes are for medical only. There are no changes to prescription drug
Employee and Family $1,338 $1,445 $107 coinsurance rates.
Employee Only $514 $542 $28
No benefits changes!
TRS-ActiveCare Employee and Spouse $1,264 $1,334 $70 This plan still has copays and the lowest deductibles, maximum
Primary+ out-of-pockets, and coinsurance rates. Your Primary Care
Employee and Children $834 $879 $45
Provider copay is $30 and TRS Virtual Health is $0.
Employee and Family $1,588 $1,675 $87
Employee Only $937 $1,013 $76
TRS-ActiveCare 2 Employee and Spouse $2,222 $2,402 $180 No benefits changes!
(closed to new This plan is still closed to new enrollees.
Employee and Children $1,393 $1,507 $114
enrollees)
Employee and Family $2,627 $2,841 $214
At a Glance
Primary HD Primary+
Premiums Lowest Lower Higher
Deductible Mid-range High Low
Copays Yes No Yes
Network Texas network Nationwide network Texas network
PCP Required? Yes No Yes
HSA-eligible? No Yes 4 No
HEALTHIER TOGETHER:
TRS-ActiveCare Plan Highlights 2021-22
IT’S TIME FOR YOUR HEALTH TO GET A BRAND-NEW START.
We’re more committed to your wellness than ever. TRS-ActiveCare’s plan designs and wide
range of wellness benefits are here to make life easier.
This year, let’s be healthier – together.
Here are some common terms:
• Premium: The monthly amount you pay for health care coverage.
• Deductible: The annual amount for medical expenses you’re responsible to pay before your plan begins to pay its portion.
• Copay: The set amount you pay for a covered service at the time you receive it. The amount can varyy by the type of service.
• Coinsurance: The portion you’re required to pay for services after you meet your deductible. It’ss often a specified percentage
percentage of the costs;
i.e. you pay 30% while the health care plan pays 70%.
• Out-of-Pocket Maximum: The maximum amount you pay each year for medical costs. After reaching the out-of-pocket maximum, the
plan pays 100% of allowable charges for covered services. 5
2021-22 TRS-ActiveCare Plan Highlights Sept. 1, 2021 – Aug. 31, 2022
How to Calculate Your All TRS-ActiveCare participants have three plan options. Each includes a wide range of wellness benefits. This plan is closed and not accepting new enrollees. If you’re
currently enrolled in TRS-ActiveCare 2, you can remain in this plan.
Monthly Premium
TRS-ActiveCare Primary TRS-ActiveCare Primary+ TRS-ActiveCare HD TRS-ActiveCare 2
Total Monthly Premium • Lowest premium of the plans • Lower deductible than the HD and Primary plans • Compatible with a health savings account (HSA) • Closed to new enrollees
• Copays for doctor visits before you meet deductible • Copays for many services and drugs • Nationwide network with out-of-network coverage • Current enrollees can choose to stay in this plan
Your District and State • Statewide network • Higher premium than the other plans • No requirement for PCPs or referrals • Lower deductible
Contributions Plan summary • PCP referrals required to see specialists • Statewide network • Must meet your deductible before plan pays for non-preventive care • Copays for many drugs and services
• Not compatible with a health savings account (HSA) • PCP referrals required to see specialists • Nationwide network with out-of-network coverage
Your Premium • No out-of-network coverage • Not compatible with a health savings account (HSA) • No requirement for PCPs or referrals
• No out-of-network coverage
Ask your Benefits Administrator for your
district’s premiums.
Monthly Premiums Total Premium Your Premium Total Premium Your Premium Total Premium Your Premium Total Premium Your Premium
Employee Only $417 $ 92 $542 $ 217 $429 $ 104 $1,013 $ 688
Wellness Benefits at Employee and Spouse $1,176 $ 851 $1,334 $ 1009 $1,209 $ 884 $2,402 $ 2077
Employee and Children $751 $ 426 $879 $ 554 $772 $ 447 $1,507 $ 1182
No Extra Cost Employee and Family $1,405 $ 1080 $1,675 $ 1350 $1,445 $ 1120 $2,841 $ 2516
Being healthy is easy with:
Plan Features
• $0 preventive care Type of Coverage In-Network Coverage Only In-Network Coverage Only In-Network Out-of-Network In-Network Out-of-Network
$1,000/$3,000 $2,000/$6,000
• 24/7 customer service Individual/Family Deductible $2,500/$5,000 $1,200/$3,600 $3,000/$6,000 $5,500/$11,000
Coinsurance You pay 30% after deductible You pay 20% after deductible You pay 30% after deductible You pay 50% after deductible You pay 20% after deductible You pay 40% after deductible
• One-on-one health coaches Individual/Family Maximum Out-of-Pocket $8,150/$16,300 $6,900/$13,800 $7,000/$14,000 $20,250/$40,500 $7,900/$15,800 $23,700/$47,400
Network Statewide Network Statewide Network Nationwide Network Nationwide Network
• Weight loss programs Primary Care Provider (PCP) Required Yes Yes No No
• Nutrition programs
• Ovia® pregnancy support Doctor Visits
$30 copay You pay 40% after deductible
• TRS Virtual Health Primary Care $30 copay $30 copay You pay 30% after deductible You pay 50% after deductible
Specialist $70 copay $70 copay You pay 30% after deductible You pay 50% after deductible $70 copay You pay 40% after deductible
• Mental health support TRS Virtual Health $0 per consultation $0 per consultation $30 per consultation $0 per consultation
• And much more!
Available for all plans. Immediate Care
See your Benefits Booklet for more details. Urgent Care $50 copay $50 copay You pay 30% after deductible You pay 50% after deductible $50 copay You pay 40% after deductible
Emergency Care You pay 30% after deductible You pay 20% after deductible You pay 30% after deductible You pay a $250 copay plus 20% after deductible
TRS Virtual Health $0 per consultation $0 per consultation $30 per consultation $0 per consultation
Things to Know Prescription Drugs
Drug Deductible Integrated with medical $200 brand deductible Integrated with medical $200 brand deductible
• TRS’s Texas-sized purchasing power
Generics (30-Day Supply/90-Day Supply) $15/$45 copay; $0 for certain generics $15/$45 copay You pay 20% after deductible; $0 for certain generics $20/$45 copay
creates broad networks without
Preferred Brand You pay 30% after deductible You pay 25% after deductible You pay 25% after deductible You pay 25% after deductible ($40 min/$80 max)/
county boundaries. You pay 25% after deductible ($105 min/$210 max)
Non-preferred Brand You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible
• Specialty drug insurance means You pay 50% after deductible ($100 min/$200 max)/
Specialty You pay 30% after deductible You pay 20% after deductible You pay 20% after deductible You pay 50% after deductible ($215 min/$430 max)
you’re covered, no matter what life
throws at you. You pay 20% after deductible ($200 min/$900 max)
6Compare Prices for Common Medical Services
Log into Blue Access for MembersSM at www.bcbstx.com/trsactivecare to use the cost estimator
REMEMBER: tool. This will help you find the best prices.
TRS-ActiveCare TRS-ActiveCare
Benefit TRS-ActiveCare HD TRS-ActiveCare 2
Primary Primary+
In-Network Only In-Network Only In-Network Out-of-Network In-Network Out-of-Network
Office/Indpendent Lab: Office/Indpendent Lab: Office/Indpendent Lab:
You pay $0 You pay $0 You pay $0
You pay 30% You pay 50% You pay 40%
Diagnostic Labs*
after deductible after deductible after deductible
Outpatient: You pay Outpatient: You pay 20% Outpatient: You pay
30% after deductible after deductible 20% after deductible
You pay 40%
You pay 20% after after deductible
You pay 30% after You pay 20% after You pay 30% You pay 50%
High-Tech Radiology deductible + $100 per + $100 per
deductible deductible after deductible after deductible
procedure copay procedure
copay
You pay 40%
You pay 20% after
after deductible
You pay 30% after You pay 20% after You pay 30% You pay 50% deductible ($150
Outpatient Costs ($150 facility
deductible deductible after deductible after deductible facility copay per
copay per
incident)
incident)
You pay 50% You pay 40%
after deductible You pay 20% after after deductible
You pay 30% after You pay 20% after You pay 30%
Inpatient Hospital Costs ($500 facility deductible ($150 ($500 facility
deductible deductible after deductible
per day facility copay per day) per day
maximum) maximum)
You pay 30% You pay 50% You pay $500
Freestanding Emergency You pay $500 copay + You pay $500 copay + You pay $500 copay +
after deductible after deductible copay + 40%
Room 30% after deductible 20% after deductible 20% after deductible
+ $500 copay + $500 copay after deductible
Facility – You pay 30% Facility – You pay 20% Facility – You pay 20%
after deductible after deductible after deductible ($150
facility copay per day)
Professional Services
Professional Services – Professional Services
– You pay $5,000
Bariatric Surgery You pay $5,000 copay + Not Covered Not Covered – You pay $5,000 Not Covered
copay + 30% after
20% after deductible copay + 20% after
deductible
deductible
Only covered if Only covered if rendered Only covered if
rendered at a BDC+ at a BDC+ facility. rendered at a BDC+
facility. facility.
Annual Vision Examination
(one per plan year; performed You pay 30% You pay 50% You pay 40%
You pay $70 copay You pay $70 copay You pay $70 copay
by an ophthalmologist or after deductible after deductible after deductible
optometrist)
Annual Hearing Exam $30 PCP copay $30 PCP copay You pay 30% You pay 50% $30 PCP copay You pay 40%
(one per plan year) $70 specialist copay $70 specialist copay after deductible after deductible $70 specialist copay after deductible
*Pre-certification for genetic and specialty testing may apply. Contact your Personal Health Guide at 1-866-355-5999 with questions.
trs.texas.gov
7
Revised 06/02/21MEMBER
INFORMATION
Providing Fast And Convenient Care
For Your Medical Needs…
COMMONLY TREATED CONDITIONS
• Allergies • Skin Infections • Respiratory Infections
• Arthritic Pain • Gastroenteritis • Sinusitis
• Cold & Flu • Ear Infection • Sprains and Strains
• Tonsillitis • Pink Eye • Urinary tract Infection
• Laryngitis • Insect Bites • Consulting for International
and Domestic Travel
• Pharyngitis • Minor Burns
• AND MUCH MORE!
• Access to licensed, board-certified physicians
• Little or no time missed from work
• No crowded waiting rooms or appointment times
HOW IT WORKS
Activate your account online at www.1800MD.com or by calling member services at
1 Activate 1.800.530.8666. Once activated, you will need to setup your member profile and
complete your electronic health record. Health and pharmacy information must be
completed before requesting a consultation.
Login to your account online or call member services at
2 Request a Consult 1.800.530.8666 to request a consult anytime 24/7.
Receive diagnosis and treatment. 1.800MD provides quality care and
3 Receive Care peace of 8mind wherever you are.What is 1.800MD?
1.800MD is a national telehealth company specializing in convenient, quality medical
care. With board-certified physicians in all 50 states*, those in need can obtain diagnosis,
treatment and a prescription, when necessary, through the convenience of a telephone
and digital communications.
*Subject to state regulations.
I have a pre-existing condition. Will 1.800MD still accept me?
Absolutely! 1.800MD is not insurance. We do not deny access to quality care because of
pre-existing conditions.
Can I get a consultation after hours or on weekends?
Yes. 1.800MD is available 24 hours a day, seven days a week and 365 days a year.
CONVENIENCE
Talk to a doctor any time, day or night, on the weekend or when traveling away from home. No
inconvenience or hassle of traveling to the doctor’s office, urgent care or ER and waiting to be
seen.
SAVES MONEY
1.800MD reduces unnecessary doctor’s office and emergency room visits. Up to 70
percent of all urgent care and emergency room visits are unneeded, costly and can be
handled with a 1.800MD telephone or video consultation.
QUALITY CARE
With an average of 15 years of internal medicine, family practice or pediatrics experience, you
can rest assured each physician is properly licensed in your state, board-certified and verified
by the National Physician Data Base and the American Medical Association.
BENEFITS
TO YOU
CONTINUITY OF CARE
Real-time access to medical records, and the ability to send them to your primary care
physi-cian or other providers.
WELLNESS AND PREVENTATIVE HEALTH TOOLS
The 1.800MD member portal contains information and tools to help you make informed
health care decisions.
E-PRESCRIPTIONS
If a 1.800MD physician recommends medication as part of your treatment plan, the
prescription will be digitally sent to the local pharmacy of your choice.
www.1800md.com
CALL 1.800.530.8666
l.800MD does not replace the primary care physician. l.800MD does
not guarantee that a prescription will be written. l.800MD operates
subject to State regulations and may not be available in certain States.
9 l.800MD does not prescribe DEA controlled substances, non-therapeutic
drugs and certain other drugs which may be harmful because of their
potential for abuse. l.800MD physicians reserve the right to deny care for
potential misuse of services.The Ultimate Peace of Mind for Employees and Their Families
The Harrison’s Story
• Jim and his family were at a local festival when his
daughter, Sara, suddenly began experiencing horrible
abdominal and back pain, after a fall from earlier
in the day.
• His wife, Heather, called 911 and Sara was transported
to a local hospital, when it was decided that she needed
to be flown to another hospital.
• Upon arrival, Sara underwent multiple procedures and
her condition was stabilized.
• After further testing, it was discovered that Sara needed
additional specialized treatment at another hospital requiring
transport on a non-emergent basis.
Based on a true story. Names were changed to protect identities in compliance with HIPAA.
And then, As a MASA Member If a Non-MASA Member
the Bills came! Sara would pay* If In-Network** If Out-of-Network**
911 Ground Ambulance
Cost: $1,800 $0 $300 $1,600
Emergent Air Ambulance
Cost: $45,000 $0 $4,000 $30,000
Non-Emergent Air Transport†
Cost: $20,000 $0 $20,000 $20,000
Total Out-of-Pocket Cost $0 $24,300 $51,600
*Benefit is dependent on Membership Enrolled.
**Out-of-pocket dollars vary dependent on provider, distance, health plan design, current status of deductible and out-of pocket max. These figures are an example of the costs one may incur.
†
More and more health plans are not covering interfacility transports on a non-emergent basis.
Any Ground. Any Air. Anywhere.TM
No matter how comprehensive your local in-network coverage may be, you still have significant exposure to out-of-network
emergency transportation. Moreover, when you and your family travel outside your area, there is an 80% chance of being
picked up by an out-of-network provider.
A MASA Membership prepares you for the unexpected. ONLY MASA MTS provides you with:
• Coverage ANYWHERE in all 50 states and Canada whether at home or away
• Coverage for BOTH emergent ground ambulance and air ambulance transport REGARDLESS of the provider
• Non-emergent transport services, which are frequently covered inadequately by your insurance, if at all
For more information, please contact your local MASA MTS representative or visit www.masamts.com
10
FLYER_COMP_B2BEMERGENCY TRANSPORTATION COSTS HOW MASA IS DIFFERENT
Across the US there are thousands of ground
MASA MTS is here to protect its members
ambulance providers and hundreds of air
and their families from the shortcomings of
ambulance carriers. ONLY MASA offers
health insurance coverage by providing them
comprehensive coverage since MASA is a
with comprehensive financial protection for
PAYER and not a PROVIDER!
lifesaving emergency transportation services,
both at home and away fromhome. ONLY MASA provides over 1.6 million
members with coverage for BOTH ground
Many American employers and employees ambulance and air ambulance
believe that their health insurance policies transport, REGARDLESS of which
cover most, if notall ambulance expenses. provider transports them.
The truth is, they DO NOT! Members are covered ANYWHERE in all 50
states and Canada!
Even after insurance payments for Additionally, MASA provides a repatriation
emergency transportation, you could receive benefit: if a member is hospitalized more than
a bill up to $5,000 for ground ambulance and 100 miles from home, MASA can arrangeand
as high as $70,000 for air ambulance. The pay to have them transported to a hospital
financial burdens for medical transportation closer to their place of residence.
costs are very real.
Any Ground. Any Air.
OUR BENEFITS Anywhere.™
Benefit* Emergent Plus
$14/mo.
Emergent Ground
Transportation U.S./Canada
Emergent Air U.S./Canada
Transportation
Non-Emergent Air
U.S./Canada
Transportation
Repatriation U.S./Canada
A MASA Membership prepares you for the
unexpected and gives you the peace of mind to
access vital emergency medical transportation no
matter where you live, for a minimal monthly fee.
• One low fee for the entire family
• NO deductibles
• NO health questions
• Easy claims process
For more information, pleasecontact
Your Broker or MASA Representative
11
* Please refer to the MSA for a detailed explanation of benefits and eligibility,
EVERY FAMILY DESERVES A MASA MEMBERSHIPPalestine ISD
Accident Insurance
Plan Summary
ACCIDENT INSURANCE BENEFITS
With MetLife, you’ll have a choice of one comprehensive plan which provide payments in addition to any other insurance payments you
may receive1. Here are just some of the covered events/services2.
Accidental Injury Benefits Plan Benefits
Fracture Benefit* $280 – $8,000 depending on the fracture and type of repair
Dislocation Benefit* $120 – $8,000 depending on the dislocation and type of repair
$75 – $10,000 depending on the degree of the burn and the
Second or Third Degree Burn Benefit
percentage of burnt skin
Concussion Benefit $300
Coma Benefit $20,000
Laceration Benefit $50 – $400 depending on the length of the cut and type of repair
Broken Tooth Benefit Crown $200 Filling $25 Extraction $100
Eye Injury Benefit $200
Accident - Medical Services & Treatment Benefits Plan Benefits
Ambulance Benefit Ground: $200 Air: $600
Emergency Care Benefit $75 – $200 depending on location of care
Non-Emergency Initial Care Benefit $75
Physician Follow-Up Visit Benefit $75
Therapy Services Benefit
$60
(including physical therapy)
Medical Testing Benefit $200
Medical Appliance Benefit $75 – $750 depending on the appliance
Transportation Benefit $800
Pain Management Benefit
$200
(for epidural anesthesia)
One device: $1,000
Prosthetic Device Benefit
More than one device: $2,000
Modification Benefit $1,000
Blood/Plasma/Platelets Benefit $600
Surgical Repair Benefit $150-$2,000 depending on the type of surgery
Exploratory Surgery Benefit $150
Other Outpatient Surgery Benefit $300
12Hospital Benefits* Plan Benefits
Admission Benefit $1,000 for the day of admission
ICU Supplemental Admission Benefit $1,000 for the day of admission
Confinement Benefit
$200 per day
(paid for up to 15 days per accident)
ICU Supplemental Confinement Benefit
$200 per day
(paid for up to 15 days per accident)
Inpatient Rehabilitation Benefit
$200 per day
(paid for up to 15 days per accident)
Accidental Death Benefit Plan Benefits
$40,000
Accidental Death Benefit*
$200,000 for accidental death on common carrier
Accidental Dismemberment, Functional Loss & Paralysis
Plan Benefits
Benefits
Dismemberment/Functional Loss $2,000 – $40,000 depending on the injury
Paralysis $15,000 - $30,000 depending on the number of limbs
Other Benefits Plan Benefits
Lodging Benefit* - for a companion of a covered person who is $200 per day
hospitalized
Health Screening Benefit $200 per day
* Notes Regarding Certain Benefits
• Fracture and Dislocation benefits – Chip fractures are paid at 25% of the applicable fracture benefit and partial dislocations are paid at 25% of the
applicable dislocation benefit.
• Hospital Benefits – Hospital does not include certain facilities such as nursing homes, convalescent care or extended care facilities. See MetLife’s
Disclosure Statement or Outline of Coverage/Disclosure Document for full details.
• Accidental Death Benefit – The benefit amount will be reduced by the amount of any accidental dismemberment/functional loss/paralysis benefits
and modification benefit paid for injuries sustained by the covered person in the same accident for which the accidental death benefit is being paid.
• Common Carrier Benefit - Common Carrier refers to airplanes, trains, buses, trolleys, subways and boats. Certain conditions apply. See your
Disclosure Statement or Outline of Coverage/Disclosure Document for specific details. Be sure to review other information contained in this booklet
for more details about plan benefits, monthly rates and other terms and conditions.
• Lodging Benefit – The lodging benefit is not available in all states. It provides a benefit for a companion accompanying a covered insured while
hospitalized, provided that lodging is at least 50 miles from the insured’s primary residence.
BENEFIT PAYMENT EXAMPLE
Benefit
Kathy’s daughter, Molly, plays soccer on the varsity high school Covered Event3
Amount
team. During a recent game, she collided with an opposing player,
was knocked unconscious and taken to the local emergency room Ambulance (ground) $200
by ambulance for treatment. The ER doctor diagnosed a concussion Emergency Care $200
and a broken tooth. He ordered a CT scan to check for facial Physician Follow-Up ($75 x2) $150
fractures too, since Molly’s face was very swollen. Molly was
Medical Testing $200
released to her primary care physician for follow-up treatment, and
her dentist repaired her broken tooth with a crown. Depending on Concussion $300
her health insurance, Kathy’s out-of-pocket costs could run into Broken Tooth (repaired by crown) $200
hundreds of dollars to cover expenses like insurance co-payments Benefits paid by MetLife
and deductibles. MetLife Group Accident Insurance payments can $1,250
Group Accident Insurance
be used to help cover these unexpected costs.
13INSURANCE RATES
MetLife offers competitive group rates and convenient payroll deduction, so you don’t have to worry about writing a check or missing a
payment! Your employee rates are outlined below.
Accident Insurance Monthly Cost to You
Coverage Options Plan
Employee $13.85
Employee & Spouse $25.48
Employee & Child(ren) $27.34
Employee & Spouse/Child(ren) $34.14
QUESTIONS & ANSWERS
Who is eligible to enroll for this accident coverage?
You are eligible to enroll yourself and your eligible family members.4 You need to enroll during your Enrollment Period and
be actively at work for your coverage to be effective.
How do I pay for my accident coverage?
Premiums will be conveniently paid through payroll deduction, so you don’t have to worry about writing a check or missing a
payment.
What happens if my employment status changes? Can I take my coverage with me?
Yes, you can take your coverage with you.5 You will need to continue to pay your premiums to keep your coverage in force.
Your coverage will only end if you stop paying your premium or if your employer offers you similar coverage with a different
insurance carrier.
Who do I call for assistance?Contact a MetLife Customer Service Representative at 1 800- GET-MET8 (1-800-438-6388),
Monday through Friday from 8:00 a.m. to 8:00 p.m., EST.
1
Covered services/treatments must be the result of a covered accident as defined in the group policy/certificate. See your Disclosure
Statement or Outline of Coverage/Disclosure Document for full details.
2
Availability of benefits varies by state. See your Disclosure Statement or Outline of Coverage/Disclosure Document for state variations.
3
Benefits and amounts are based on sample MetLife plan design. Plan design and plan benefits may vary.
4
Coverage is guaranteed provided (1) the employee is actively at work and (2) dependents to be covered are not subject to medical
restrictions as set forth on the enrollment form and in the Certificate. Some states require the insured to have medical coverage.
5
Eligibility for portability through the Continuation of Insurance with Premium Payment provision may be subject to certain eligibility
requirements and limitations. For more information, contact your MetLife representative.
METLIFE’S ACCIDENT INSURANCE IS A LIMITED BENEFIT GROUP INSURANCE POLICY. The policy is not intended to be a substitute
for medical coverage and certain states may require the insured to have medical coverage to enroll for the coverage. The policy or its
provisions may vary or be unavailable in some states. There are benefit reductions that begin at age 65, if applicable. Like most group
accident and health insurance policies, policies offered by MetLife may include waiting periods and contain certain exclusions, limitations and
terms for keeping them in force. For complete details of coverage and availability, please refer to the group policy form GPNP12-AX or
contact MetLife.
Benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. Hospital does not include certain facilities such as
nursing homes, convalescent care or extended care facilities. See MetLife’s Disclosure Statement or Outline of Coverage/Disclosure
Document for full details.
Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166
L0819517025[exp1020][All States]© 2019 MetLife Services and Solutions, LLC
14Palestine Independent School District
Critical Illness
Plan Highlights
Policy Number 474777
Critical Illness insurance provides financial protection by paying a lump sum benefit if you are
diagnosed with a covered critical illness.
Who is eligible for All employees in active employment in the United States working at least 15 hours
this coverage? per week and their eligible spouses and children (up to age 26 regardless of student
or marital status).
What are the Critical The following coverage amounts are available.
Illness coverage
amounts? For you: Select one of the following
$10,000, $15,000 or $20,000
For your Spouse: 100% of employee coverage amount
For your Children: 50% of employee coverage amount
Can I be denied Coverage is guarantee issue.
coverage?
When is coverage Please see your Plan Administrator for your effective date of coverage.
effective?
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.
What critical Covered Conditions*
illness conditions Percentage of
are covered? Coverage Amount
Critical Illnesses
Coronary Artery Disease (major) 50%
Coronary Artery Disease (minor) 10%
End Stage Renal (Kidney) Failure 100%
Heart Attack (Myocardial Infarction) 100%
Major Organ Failure Requiring Transplant 100%
Stroke 100%
Cancer
Invasive Cancer (including all Breast Cancer) 100%
Non-Invasive Cancer 25%
Skin Cancer $500
Supplemental Critical Illnesses
Benign Brain Tumor 100%
Coma 100%
Loss of Hearing 100%
Loss of Sight 100%
Loss of Speech 100%
Infectious Disease 25%
Occupational Human Immunodeficiency Virus 100%
(HIV) or Hepatitis
Permanent Paralysis 100%
15Progressive Diseases
Amyotrophic Lateral Sclerosis (ALS) 100%
Dementia (including Alzheimer’s Disease) 100%
Functional Loss 100%
Multiple Sclerosis (MS) 100%
Parkinson’s Disease 100%
Additional Critical Illnesses for your Children
Cerebral Palsy 100%
Cleft Lip or Palate 100%
Cystic Fibrosis 100%
Down Syndrome 100%
Spina Bifida 100%
*Please refer to the policy for complete definitions of covered conditions.
Covered Condition Benefit
The covered condition benefit is payable once per covered condition per insured.
Unum will pay a covered condition benefit for a different covered condition if:
- the new covered condition is medically unrelated to the first covered condition;
or
- the dates of diagnosis are separated by more than 180 days.
Reoccurring Condition Benefit
We will pay the reoccurring condition benefit for the diagnosis of the same covered
condition if the covered condition benefit was previously paid and the new date of
diagnosis is more than 180 days after the prior date of diagnosis.
The benefit amount for any reoccurring condition benefit is 100% of the percentage
of coverage amount for that condition.
The following Covered Conditions are eligible for a reoccurring condition benefit:
Benign Brain Tumor Heart Attack (Myocardial Infarction)
Coma Invasive Cancer (includes all Breast Cancer)
Coronary Artery Disease (Major) Major Organ Failure Requiring Transplant
Coronary Artery Disease (Minor) Non-Invasive Cancer
End Stage Renal (Kidney) Failure Stroke
Are wellness Each insured is eligible to receive one Be Well Benefit per calendar year.
screenings
covered? Be Well Benefit
For you, your spouse and your children: $50
If the employee’s Critical Illness The Be Well Benefit Amount for you,
Coverage Amount is: your spouse and your children is:
$10,000 $50
$15,000 $50
$20,000 $50
Be Well Screenings include tests for the following:
cholesterol and diabetes, cancer and cardiovascular function. They also include
imaging studies, immunizations and annual examinations by a Physician. See
certificate for details.
16How much does Option 1
the coverage cost?
Monthly Critical Illness Cost
$10,000 EE, $10,000 SP, $50 Be Well Benefit
Age Employee Cost Spouse Cost
Less than age 25 $3.84 $3.84
25-29 $4.74 $4.74
30-34 $5.84 $5.84
35-39 $7.84 $7.84
40-44 $10.24 $10.24
45-49 $13.34 $13.34
50-54 $16.94 $16.94
55-59 $22.84 $22.84
60-64 $31.84 $31.84
65-69 $45.94 $45.94
70-74 $71.04 $71.04
75-79 $104.24 $104.24
80-84 $151.14 $151.14
85 or over $242.94 $242.94
Option 2
Monthly Critical Illness Cost
$15,000 EE, $15,000 SP, $50 Be Well Benefit
Age Employee Cost Spouse Cost
Less than age 25 $4.84 $4.84
25-29 $6.19 $6.19
30-34 $7.84 $7.84
35-39 $10.84 $10.84
40-44 $14.44 $14.44
45-49 $19.09 $19.09
50-54 $24.49 $24.49
55-59 $33.34 $33.34
60-64 $46.84 $46.84
65-69 $67.99 $67.99
70-74 $105.64 $105.64
75-79 $155.44 $155.44
80-84 $225.79 $225.79
85 or over $363.49 $363.49
17Option 3
Monthly Critical Illness Cost
$20,000 EE, $20,000 SP, $50 Be Well Benefit
Age Employee Cost Spouse Cost
Less than age 25 $5.84 $5.84
25-29 $7.64 $7.64
30-34 $9.84 $9.84
35-39 $13.84 $13.84
40-44 $18.64 $18.64
45-49 $24.84 $24.84
50-54 $32.04 $32.04
55-59 $43.84 $43.84
60-64 $61.84 $61.84
65-69 $90.04 $90.04
70-74 $140.24 $140.24
75-79 $206.64 $206.64
80-84 $300.44 $300.44
85 or over $484.04 $484.04
Your rate is based on your insurance age, which is your age immediately prior to and
including the anniversary/effective date.
Spouse rate is based on your Spouse’s insurance age, which is their age immediately
prior to and including the anniversary/effective date.
Do my critical Critical Illness benefits do not decrease due to age.
illness insurance
benefits decrease
with age?
Are there any
exclusions or We will not pay benefits for a claim that is caused by, contributed to by, or occurs as
limitations? a result of any of the following:
- committing or attempting to commit a felony;
- being engaged in an illegal occupation or activity;
- injuring oneself intentionally or attempting or committing suicide, whether sane
or not;
- active participation in a riot, insurrection, or terrorist activity. This does not
include civil commotion or disorder, injury as an innocent bystander, or Injury for
self-defense;
- participating in war or any act of war, whether declared or undeclared;
- combat or training for combat while serving in the armed forces of any nation or
authority, including the National Guard, or similar government organizations;
- voluntary use of or treatment for voluntary use of any prescription or non-
prescription drug, alcohol, poison, fume, or other chemical substance unless
taken as prescribed or directed by the Insured’s Physician;
- being intoxicated; and
- a Date of Diagnosis that occurs while an Insured is legally incarcerated in a penal
or correctional institution.
Additionally, no benefits will be paid for a Date of Diagnosis that occurs prior to the
coverage effective date.
18Pre-existing Conditions
We will not pay benefits for a claim when the covered loss occurs in the first 12
months following an insured’s coverage effective date and the covered loss is caused
by, contributed to by, or occurs as a result of any of the following:
- a pre-existing condition; or
- complications arising from treatment or surgery for, or medications taken for, a
pre-existing condition.
An insured has a pre-existing condition if, within the 3 months just prior to their
coverage effective date, they have an injury or sickness, whether diagnosed or not,
for which:
- medical treatment, consultation, care or services, or diagnostic measures were
received or recommended to be received during that period;
- drugs or medications were taken, or prescribed to be taken during that period;
or
- symptoms existed.
Pre-existing Condition requirements are not applicable to children who are newly
acquired after your Coverage Effective Date.
The pre-existing condition provision applies to any Insured’s initial coverage and any
increases in coverage. Coverage effective date refers to the date any initial coverage
or increases in coverage become effective.
Is the coverage If your employment with your employer ends or you are no longer in an eligible group
portable (can I you can apply for ported coverage and pay the first premium within 31 days to
keep it if I leave continue coverage for yourself, your spouse and your children.
my employer)?
If your spouse’s coverage ends as a result of your death, divorce or annulment, your
spouse may elect to continue spouse and children coverage, as long as premium is
paid as required.
When does my If you choose to cancel coverage, it will end on the first of the month following the
coverage end? date you provide notification to your employer.
Otherwise, coverage ends on the earliest of:
- the date the policy is cancelled by your employer;
- the date you no longer are in an eligible group;
- the date your eligible group is no longer covered;
- the date of your death
- the last day of the period any required contributions are made;
- the last day you are in active employment.
If you choose to cancel your Spouse’s coverage, it will end on the first of the month
following the date you provide notification to your employer.
Otherwise, your spouse’s coverage will end on the earliest of:
- the date your coverage ends;
- the date your spouse is no longer eligible for coverage;
- the date your spouse no longer meets the definition of a spouse;
- the date of your spouse’s death; or
- the date of divorce or annulment.
19Your children’s coverage will end on the earliest of:
- the date your coverage ends;
- the date your children are no longer eligible for coverage; or
- the date your children no longer meet the definition of children.
The limited benefits provided are a supplement to major medical coverage and are not a substitute for major medical coverage or
other minimal essential coverage as required by federal law. Lack of minimal essential coverage may result in an additional tax payment
being due.
This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may
vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete
details of coverage and availability, please refer to Policy Form GCIP16-1 et al or contact your Unum representative.
© 2018 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring
subsidiaries.
Underwritten by Unum Insurance Company, Portland, Maine
AE-1226 FOR EMPLOYEES
20The solution to your benefit
problems...
n e c t i o n
n n sura nce
I
e nse
o e d i c al
E xp
tC
M
al
nt
me
Benefi
ple
Sup
Group
Underwritten by
21TODAY’S EMPLOYEES ARE CONCERNED WITH: THE SOLUTION TO YOUR
• Taking Care of their Family’s Health
BENEFIT PROBLEMS…
• Rising Cost of Group Major Medical Premiums
• Increasing Deductibles, Co-Payments and Co-Insurance
• The Rising Cost of Healthcare
Benefit
*Employee contributions to health insurance premiums have increased 168%
from 1999 to 2011.
Connection
Benefit Connection covers portions of the
EMPLOYERS FEEL THE PRESSURE OF:
expenses employees and their families incur due
• Offering Employees Comprehensive Affordable Health Care
to treatment of injuries and illnesses under their
• Retaining and Attracting Quality Employees
major medical plan as a result of the application
• Managing Major Group Medical Plans and Spiraling Cost
of deductibles and coinsurance.
*From 1999 to 2011, the average annual amount of employee contributions to health
insurance premiums has increased from $318 to $921 for employee’s coverage and from An underlying major medical plan is required.
$1,543 to $4,129 for family coverage.
This product does not pay 100% of out-of-
A pocket expenses.
BENEFIT ADVISORS ARE SEEKING SOURCES
THAT WILL:
• Control Employee Benefits Cost
• Initiate New Ideas
• Create Solutions
• Simplify the Process
BASIC PRODUCT FEATURES
*Among firms with 3-999 employees offering health benefits, the percentage that offer • Expenses must be covered by the insured’s
an HDHP has risen from 4% in 2005 to 23%-26% in 2011. For firms with 1,000 or
more employees that number has increased from 8% to 41%. major medical plan for benefits to be paid
under this product.
*Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits 1999-2011. • Provides coverage for medically necessary
eligible out-of-pocket expenses related to the
insured’s major medical plan’s co-insurance
and deductibles up to the maximum benefit
selected, provided such expenses are the result
of treatment for an injury or sickness.
• Includes a range of benefit maximums available
to allow plan designs that correspond with the
insured’s major medical plan’s out-of-pocket
expenses.
• Basic product benefits are for in-hospital
charges only, including emergency room
treatment for an injury or for a sickness, if
the sickness results in a hospital confinement
within 24 hours. Optional coverages include
outpatient treatment, physician office visits,
and Term Life/AD&D.
• Uses itemized bills and primary major medical
plan’s EOB (explanation of benefits) as a basis
for determining what is covered.
22INPATIENT HOSPITAL BENEFIT
Benefit Amount Options: $500 to $10,000 per covered person
per calendar year/benefit year.
BENEFITS INCLUDE
• Coverage for out-of-pocket expenses due to an inpatient
hospital confinement
• Coverage for inpatient hospital stays, inpatient surgeries,
and physician’s in-hospital charges for eligible out-of-pocket
expenses resulting from the treatment of an injury or sickness
• Coverage for out-of-pocket expenses due to emergency room
treatment for an injury or sickness (ER treatment is covered
under the Inpatient Hospital Benefit only if coverage is NOT
purchased with the Outpatient Benefit)
The benefit amount should coincide with the
deductibles/copays/coinsurance established COVERED HOSPITAL STAY + SURGERY EXAMPLE *
under the major medical plan. Maximum
A Hospital Stay + Surgery = $18,000 Total Expenses
inpatient benefit level should not exceed the
total amount of the individual in-network With
deductible and coinsurance maximum under Without
$5,000
the major medical plan. IHB
IHB
Routine newborn nursery care and well-baby Deductible $2,500 $2,500
care is not a covered expense.
Coinsurance (20%) $3,100 $3,100
Benefits for emergency room treatment due
Total Out-of-Pocket $5,600 $5,600
to sickness require that the sickness result in
hospital confinement within 24 hours of the Inpatient Hospital Benefit
hospital emergency room treatment, otherwise $0 $5,000
(IHB)
it would apply to the Outpatient Benefit
(if included). TOTAL OUT-OF-POCKET $5,600 $600
Hospital Confinements due to pregnancy are
covered for insured employees and their insured
spouses, if payable under the major medical
plan. Pregnancy (except for complications
of pregnancy) is not covered for dependent
children, unless required by state law.
23OUTPATIENT BENEFIT
(OPTIONAL)
Outpatient benefits may include, but are not limited to:
• Hospital emergency room treatment of injury or sickness
• Outpatient surgery in an outpatient surgical facility,
emergency facility or physician’s office
• Diagnostic testing including, but not limited to, x-rays,
diagnostic lab, MRI’s, and CT scans
• Outpatient radiation therapy or chemotherapy
• Physical therapy or chiropractic care
• Durable medical equipment if dispensed to the insured
person in a hospital or provider’s office. DME is otherwise
not covered.
The Outpatient Benefit does not cover a physician’s office
visit charge. In order to have this type of charge covered,
the Physician Benefit would need to be purchased as part of
the Policy.
A
Two optional outpatient benefits are available for the employer
to choose from:
OUTPATIENT I OR OUTPATIENT II
OUTPATIENT I
OUTPATIENT I ($2,500 BENEFIT EXAMPLE) * Benefits range from a minimum of $200 to
a maximum of $2,500 provided the maximum
Out- of-
Benefit benefit selected is not greater than the amount
Occurrence Pocket
Amount of Inpatient Hospital Benefit selected.
Cost
Occurrence #1 $2,750 $2,500 The Outpatient I benefit pays on a “per person
per Sickness or Injury” basis, up to a maximum
Occurrence #2 $2,000 $2000 of 3 “occurrences” per family per calendar
year. This maximum applies to the entire family
Occurrence # 3 $1,000 $1,000 unit, regardless of the number of covered
persons within the family unit. An “occurrence”
TOTAL $5,750 $5,500
is the treatment, or series of treatments, for a
TOTAL PAID BY INSURED = $250 specific sickness or injury in a calendar year. All
expenses related to the treatment of the same or
related sickness or injury will accrue toward the
outpatient maximum for one occurrence. When
that amount has been reached, no additional
charges would be considered for that diagnosis
until incurred in a new calendar year.
24OUTPATIENT II
OUTPATIENT II ($2,500 BENEFIT EXAMPLE) *
Benefits are available as an alternative to
Outpatient I benefits. Available benefit limits Out- of-
range from a minimum of $250 to a maximum Based on total amount of Benefit
Pocket
of $2,500, provided the maximum benefit charges in a calendar year Amount
Cost
selected is not greater than 50% of the amount
of Inpatient Hospital Benefit selected. Employee $2,750 $2,500
The Outpatient II benefit pays on a “per person Child $3,000 $2,500
per calendar year” or benefit year basis, with a
family maximum limit of two (2) times the “per Spouse $500 $0
person” limit. This maximum applies to the
TOTAL $6,250 $5,000
entire family unit, regardless of the number of
covered persons within the family unit, however, TOTAL PAID BY INSURED = $1,250
the benefit payable for no one person within the
family unit can exceed the “per person” limit.
*Claims examples are for illustrative purposes only. Each insured person’s coverage may be different based on the plan selected and their specific situation.
All benefits are subject to the exclusions and limitations outlined in the policy and riders. The examples listed herein assume that all incurred charges are
covered under this supplemental medical expense policy, no incurred charges are excluded, and no limitations have been applied.
25PHYSICIAN BENEFIT
(OPTIONAL)
This optional benefit pays for physician services for treatment
of an injury or sickness. Services must be received in a
physician’s office, hospital, emergency facility or outpatient
facility. The provider must use an office visit/consultation
code in order for benefits to be paid.
The Employer can choose from two Physician Office Visit
Benefit structures:
• $15 per visit up to the lesser of $120 per calendar year
or 8 visits per family per calendar year; or
• $20 per visit up to the lesser of $240 per calendar year
or 12 visits per family per calendar year.
TERM
A LIFE AND AD&D BENEFIT RIDER
(OPTIONAL)
The Employer may choose to include $5,000, $10,000,
$15,000, or $20,000 of Life and AD&D coverage for ELIGIBILITY
each employee participating in the Supplemental Medical Any employee working 20 or more hours per
Expense plan. Benefits reduce by 50% at age 70 and another week is eligible for coverage.
50% at age 75.
RESTRICTED INDUSTRIES
DEPENDENT TERM LIFE BENEFIT Professional Employer Organizations (PEO’s)
• Spouse coverage equals 50% of the employee’s term life are subject to prior carrier approval.
insurance amount.
• Child coverage equals 25% of the employee’s term life
insurance amount for dependents age 6 months and up
EFFECTIVE DATE
Employees will not be covered until the
and 2.5% for infants 14 days to 6 months.
application has been accepted and the
• Dependents’ life coverage terminates when base medical
premium has been paid. All insureds will
coverage eligibility ceases.
be effective on the 1st day of the month.
All benefits listed above are subject to the exclusions and limitations outlined in the policy and Enrollment follows those guidelines established
rider. for enrollment in the underlying group major
medical plan.
CLAIM SUBMISSIONS
To claim benefits the insured person must
submit a claim form (only one per calendar
year is required), and either the insured
person or provider must submit copies of the
fully itemized bills and copies of the EOB’s
(explanation of benefits) from the major medical
carrier.
26You can also read
