2021 EMPLOYEE BENEFITS GUIDE - Archdiocese of Galveston ...
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2021 EMPLOYEE BENEFITS GUIDE
Your 2021 Medical Pharmacy Dental Vision Life, AD&D Additional
Benefits Benefits Benefits Benefits Benefits Disability Benefits
YOUR 2021
BENEFITS
The benefits described in this guide are effective January 1—December 31, 2021.
Welcome!
The Archdiocese of Galveston-Houston is proud to offer a comprehensive benefits package that can be
customized to meet the needs of you and your family. We are committed to promoting better health for our Lay
employees and their eligible dependents. This means you have access to annual physicals and more—all at no
cost to you. Please review this guide carefully and consider your options so that you can make the best
choices for you and your dependents.
Each year during the open enrollment process, we engage in a detailed review of our benefits programs and
related costs, evaluate coverage options, leverage and contain costs, and identify additional programs and
services to offer. We strive to provide our employees a best-in-class benefits program, with high value benefits
offered at an affordable cost.
This benefit guide has been prepared to summarize the many benefit programs and plans available to our
eligible employees. Please read this information carefully. This benefit guide is a summary and not intended to
be comprehensive, so please refer to the plan documents pertaining to each plan for more information.
Please note: effective January 1, 2021, Continuation of Benefits (COB) will no longer be offered. If you are
currently a COB participant, your COB coverage will end on December 31, 2020. If your employment and
health coverage through the Archdiocese of Galveston-Houston ends, there are a number of health coverage
options we encourage you to explore, including the Healthcare Marketplace (www.healthcare.gov). For more
information, please reference the “When Your Coverage Ends” document posted on the Archdiocese of
Galveston-Houston Human Resources website.
Open Enrollment
Open Enrollment begins October 1st and ends November 4th, 2020. Any changes you make to your benefit
elections during Open Enrollment will become effective on January 1, 2021. To enroll or make changes to your
benefit elections, you must log on to the ADP web portal. Please see the instructions on the following page for
details.
If you and/or your dependents have Medicare or will become eligible for Medicare in
the next 12 months, a federal law gives you more choices about your prescription
drug coverage. Please see the separate legal disclosure booklet for more details.
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Enrolling in Benefits
You can complete your enrollment quickly and easily online by
logging onto ADP. Follow these steps to get started:
1 Go to www.workforcenow.adp.com
Log into ADP using your username and password. For login help or
2
to reset your password, click on “Forgot Your User ID/Password?”
Detailed instructions are available on the Human Resources website:
3
www.archgh.org/offices-ministries/administration/human-resources
Determining Eligibility
You are eligible for benefits if you are a regular, full-time employee who is scheduled to work at least 30 hours
per week. For clergy, religious, school teachers and principals, benefits become effective on the first of the
month following or coinciding with your date of hire. For lay persons, benefits become effective on the first of
the month following or coinciding with 60 days of active employment.
The Archdiocese of Galveston-Houston also offers Medical/Rx, Dental, and Vision coverage to your eligible
dependents. Eligible family members include:
Your opposite sex legal spouse
Your dependent children up to age 26
A child over the age of 26 who is handicapped and chiefly depends on you for support
Eligible dependent children include your biological child, stepchild, legally adopted child (including a child for
whom legal adoption proceedings have been initiated), a child whose parent is your child and your child is
covered as a dependent under the plan, and a child for whom you have obtained legal guardianship or for
whom benefits must be provided under a Qualified Medical Child Support Order (QMCSO).
Dependent Verification
The Archdiocese of Galveston-Houston requires documentation to establish confirmation of dependent
eligibility at any time. Please review the above eligibility criteria to ensure your dependents meet the definition
of an eligible dependent. Dependents will not be enrolled in the plan without supporting documentation. If
you have questions about the documentation required to confirm eligibility for your dependent(s), please
contact Human Resources.
Changing Your Benefits During the Year
The benefit choices you make during open enrollment will remain in effect for the entire plan year (January 1—
December 31) unless you have a Qualifying Life Event. Qualifying Life Events include but are not limited to:
Marriage or divorce
Birth or adoption of a child
Change in employment for you or your spouse that affects your benefit eligibility
Loss or gain of other health coverage
You have 31 calendar days following the date of the Qualifying Life Event to submit your benefit election
changes. Please note supporting documentation is required. Any changes you make must be related to the
status change, as required by IRS regulations.
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The Benefits Help Line
The Archdiocese of Galveston-Houston Benefits Help Line is a
valuable resource for your health, welfare, and insurance
benefits. Talk to a personal benefits advocate about your
eligibility, enrollment, benefit questions, finding a provider,
billing or claim questions, and more!
The Benefits Help Line is available Monday—Friday, 7:00 AM
to 6:00 PM Central Time.
855-664-8164 agh_benefits@ajg.com
Important Contacts
Benefit Vendor Phone Website/Email
Archdiocese of
Human Resources 713-652-8265 www.archgh.org
Galveston-Houston
Medical Blue Cross Blue Shield
800-521-2227 www.bcbstx.com
(Group #274679) of Texas (BCBSTX)
Prescription Drugs OptumRx 1-855-524-0381 www.optumrx.com
Virtual Visits MDLive 888-680-8646 www.mdlive.com/bcbstx
Blue Cross Blue Shield
Nurseline 800-581-0393 N/A
of Texas (BCBSTX)
Diabetes Support Livongo 800-945-4355 join.livongo.com/ARCHGH
(Registration Code: ARCHGH)
Dental Blue Cross Blue Shield
800-521-0393 www.bcbstx.com
(Group #274852) of Texas (BCBSTX)
Vision VSP 1-800-877-7195 www.vsp.com
(Group #12001362)
Life and AD&D The Standard 1-833-229-4173 www.standard.com
(Group #756955)
Disability & Leave
Management The Standard 1-833-229-4173 www.standard.com/absence
(Group #756955)
Employee Assistance The Standard 888-293-6948
Program www.workhealthlife.com/Standard3
(Morneau Shepell) TTY: 800-327-1833
(Group #756955)
USA, Canada, Puerto Rico, USVI medservices@assistamerica.com
The Standard & Bermuda: 800-872-1414 Reference Number: 01-AA-STD-5201
Travel Assistance
(Assist America) Worldwide: +1-609-986-1234 Download the Assist America Mobile
Text: +1-609-334-0807 App on the App Store or Google Play
www.standard.com/mytoolkit
Life Services Toolkit The Standard 800-378-5742
Username: assurance
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MEDICAL
BENEFITS
The Archdiocese of Galveston-Houston offers two medical plans through Blue Cross Blue Shield of Texas
(BCBSTX). The Archdiocese pays 100% of the “employee only” premium for all eligible employees. If you have
eligible dependents, you pay a premium for dependent coverage (see page 12). Employees choosing
“employee only” coverage are enrolled in the Standard Plan. Employees who wish to cover their eligible
dependents can choose to enroll in either the Standard Plan or the Economy Plan.
Medical Services Standard Plan Economy Plan
BCBSTX Blue Choice Network In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible $800 / $1,600 $1,600 / $3,200 $1,200 / $2,400 $2,400 / $4,800
Individual / Family
You pay 20% after You pay 50% after You pay 30% after You pay 50% after
Coinsurance
deductible deductible deductible deductible
Out-of-Pocket Maximum $3,300 / $6,600 $6,000 / $12,000 $7,000 / $14,000 $12,000 / $24,000
Individual / Family
Preventive Care Plan pays 100% 50% after deductible Plan pays 100% 50% after deductible
Primary Care Office Visit $25 copay 50% after deductible $35 copay 50% after deductible
Specialist Office Visit $40 copay 50% after deductible $50 copay 50% after deductible
MDLive Virtual Visit $25 copay Not Covered $35 copay Not Covered
Urgent Care Center $40 copay 50% after deductible $40 copay 50% after deductible
Emergency Room $170 copay $170 copay $230 copay $230 copay
(copay waived if admitted) (copay waived if admitted) (copay waived if admitted) (copay waived if admitted)
Diagnostic Tests Plan pays 100% 50% after deductible Plan pays 100% 50% after deductible
X-ray, labs, blood work (LabCorp or Quest Diagnostics) (LabCorp or Quest Diagnostics)
Imaging 20% after deductible 50% after deductible 30% after deductible 50% after deductible
MRI, CT/PET Scan
Inpatient Services 20% after deductible 50% after deductible 30% after deductible 50% after deductible
Outpatient Services 20% after deductible 50% after deductible 30% after deductible 50% after deductible
The Archdiocese of Galveston-Houston believes its Medical and Pharmacy Plan as described in this guide is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (PPACA). As
permitted by PPACA, a grandfathered health plan must preserve certain basic health coverage that was already in the Plan when that law was enacted. Being a grandfathered health plan means that your
Plan may not include certain consumer protections (health and pharmaceutical coverages) of PPACA that apply to other (non-grandfathered) plans, for example, the requirement for the provision of
preventive health services without any cost sharing. However, the grandfathered plans must comply with certain other consumer protections in PPACA, for example, the elimination of lifetime limits on
benefits. As a grandfathered plan, this Plan, self-funded by the Archdiocese of Galveston-Houston, does not provide medical and pharmaceutical coverage that contravenes with Catholic teachings.
Questions regarding which protections (Medical and Pharmaceutical coverages) apply and which protections (Medical and Pharmaceutical coverages) do not apply to our grandfathered health plan status
can be directed to the plan administrator, Charlie Pavlovsky, at 713-652-8261.
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24/7 Nurseline
Health happens—good or bad, 24 hours a day, 7 days a week. That
is why BCBSTX has registered nurses waiting to talk to you
whenever you call the 24/7 Nurseline. Registered nurses are
available to answer health questions and to help you decide
whether you should go to the emergency room, urgent care, or
make an appointment with your doctor. Plus when you call, you can
also access an audio library of more than 1,000 health topics—from
allergies to surgeries—with more than 500 topics available in
Spanish. Call the 24/7 Nurseline anytime at 800-581-0393.
Blue Access For Members
Get information about your health benefits anytime, anywhere. Use your computer, phone or tablet to access
the Blue Cross Blue Shield of Texas (BCBSTX) secure member website, Blue Access for Members. With Blue
Access for Members, you can:
Provider Finder
Locate a doctor, hospital or facility in the BCBSTX Blue Choice PPO Network
ID Cards
Request a new ID card, or print a temporary one
Wellness Tools & Resources
Access handy tools like Well onTarget, which has fitness trackers, food diaries,
and more
Claims
View or print Explanation of Benefits statements, and check the status or
history of a claim
My Coverage
See your benefits at a glance or in detail
Customer Service
Use secure messaging to get in touch with helpful customer service
representatives
It’s easy to get started! Visit www.bcbstx.com/member and click on “Register Now” under the blue Member
Login button. You will need the information on your BCBSTX ID card to complete your registration. If you do
not have this information, you can call the BCBSTX Help Desk at 888-706-0583 for assistance.
BCBSTX Mobile App
IT’S EASY TO GET Many of the services and resources available through Blue Access for
Members can also be found right in the palm of your hand! With the
CONNECTED BCBSTX Mobile App, you can access your important health plan
information wherever you are. Text* BCBSTXAPP to 33633 to get the
app, or download it directly from the App Store or Google Play.
*Message and data rates may apply. Terms and conditions and privacy policy at bcbstx.com/mobile/text-messaging.
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Blue365 Discounts
Blue365 is just one more advantage you have by being a Blue Cross Blue Shield of Texas (BCBSTX) member!
With this program, you may save money on health and wellness products and services from top retailers that
are not covered by insurance. There are no claims to file and no referrals or preauthorizations.
Once you sign up for Blue365 at blue365deals.com/bcbstx, weekly “Featured Deals” will be emailed to you.
These deals offer special savings for a short period of time. Below are some of the ongoing deals you can
access on the Blue365 website:
EyeMed | Davis Vision
You can save on eye exams, eyeglasses, contact lenses and accessories. You have
access to national and regional retail stores and local eye doctors. You may also get
possible savings on laser vision correction.
TruHearing® | Beltone™ | American Hearing Benefits
You could get savings on hearing tests, evaluations and hearing aids. Discounts may
also be available for your immediate family members.
Jenny Craig® | Sun Basket | Nutrisystem®
Help reach your weight loss goals with savings from leading programs. You may save
on healthy meals, membership fees (where applicable), and nutritional products and
services.
Fitbit®
You can customize your workout routine with Fitbit’s family of trackers and
smartwatches that can be employed seamlessly with your lifestyle, your budget, and
your goals. You’ll get a 20% discount on Fitbit devices plus free shipping.
Reebok | SKECHERS®
Reebok makes top athletic equipment for all people, from professional athletes to kids.
Get 20% off select models. SKECHERS, a leader in the footwear industry, offers
exclusive pricing on men’s and women’s styles—get 30% off plus free shipping online.
Livekick
Livekick is the future of private fitness. Choose from training or yoga over live video with
a private coach. Get fit and feel healthier with action-packed 30-minute sessions that
you can do from home or in the gym. Get a free 2-week trial and 20% off a monthly plan.
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PHARMACY
BENEFITS
The Archdiocese of Galveston-Houston Medical/Rx plans include comprehensive prescription drug coverage.
You are automatically enrolled in prescription drug coverage when you enroll in either the Standard Plan or the
Economy Plan. Our prescription drug benefits administered by OptumRx.
Prescription Drug Benefits Standard Plan Economy Plan
OptumRx In-Network Out-of-Network In-Network Out-of-Network
Retail Pharmacy
30-day supply
Generic $10 copay 50% after $10 copay $10 copay 50% after $10 copay
*
Preferred Brand $50 copay 50% after $50 copay $55 copay 50% after $55 copay
*
Non-Preferred Brand $75 copay 50% after $75 copay $80 copay 50% after $80 copay
OptumRx Home Delivery
90-day supply
Generic $5 copay Not Covered $5 copay Not Covered
*
Preferred Brand $95 copay $105 copay
*
Non-Preferred Brand $145 copay $155 copay
* For certain preferred brand and non-preferred brand drugs, you may be required to try a generic equivalent first. See below for more details.
About Step Therapy
The Step Therapy Program encourages safe and cost-effective medication use. The program is designed to
keep members safe and save money when possible. To receive coverage for certain medications, you may
need to first try a proven, generic equivalent before using a more costly treatment, if needed. For a complete
list of drugs covered by your plan, as well as a list of Step Therapy drugs, visit www.optumrx.com.
Generic Drugs Non-Preferred Brand Drug Preferred Brand Drug
You can save on your out-of-pocket A name brand drug that may have a Preferred brand drugs are commonly
TERMS TO costs by choosing generic drugs.
Brand and generic drugs are
regulated by the FDA and are
therapeutic alternative available as
either a generic or preferred brand
drug. These drugs will generally be
prescribed name-brand drugs that
has been selected based on its
clinical effectiveness, safety, and
KNOW
chemically and medically the same. the most expensive. cost. Preferred brand drugs will
However, generic drugs typically generally be more expensive than
cost significantly less. Talk to your Formulary generic drugs, but less expensive
doctor to find out if generic drugs The list of prescription drugs covered than non-preferred brand drugs.
are right for you. by the plan. Also called a “drug list.”
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Save with Generic Drugs
Both prescription and over-the-counter generic drugs
can be less costly than brand name drugs. You can
save on your out-of-pocket costs by choosing
generic medications. Both brand and generic drugs
are regulated by the Food and Drug Administration
(FDA) and are chemically and medically the same.
However, generic drugs tend to cost significantly less
than their brand name equivalents! We encourage
you to talk to your doctor to find out if generic drugs
are right for you.
OptumRx Mail Saver
Do you take medicine every day for diabetes, asthma, or another condition? These are called maintenance
medications. Mail Service Saver is a program that helps you better manage your maintenance medications on
an ongoing basis. You can save both time and money by filling your prescriptions for maintenance
medications through OptumRx Home Delivery. Not only is home delivery safe and reliable, it also offers some
advantages:
Cost Savings — You may pay less for your medication
with a 90-day supply from OptumRx Home Delivery.
Convenience — Get free standard shipping on
medications delivered to your mailbox.
24/7 Access & Reminders — Speak to a licensed
pharmacist who can answer your questions any time,
any day. You can even set up text reminders to help you
remember to take or refill your medications.
Please note that all maintenance medications are required to participate in the OptumRx Home Delivery
program after 60 days. You may fill your prescription at a retail pharmacy for the first 60 days (i.e. two 30-
day fills). After 60 days, you must fill your prescription through OptumRx Home Delivery. If you try to fill a
maintenance medication at a retail pharmacy after the 60-day retail grace period, your medication will NOT
be covered.
OptumRx Member Website & Mobile App
From the OptumRx member website and mobile app, you can easily
refill a medication, transfer a retail prescription to home delivery,
IT’S EASY TO GET
access the most current drug coverage information, compare potential
cost savings, and more! To register, visit www.optumrx.com or
download the OptumRx Mobile App from the App Store or Google Play.
CONNECTED
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TELEHEALTH
BENEFITS
Get Care When and Where You Need It
MDLive provides you and your covered dependents with access to board-certified doctors anytime and
anywhere it’s most convenient for you—at home, work, or on the go. MDLive has the nation’s largest telehealth
network of doctors ready to provide convenient, quality care by phone or secure video. Doctors can diagnose a
wide range of non-emergency medical issues and even send prescribed medications to your pharmacy of
choice. MDLive physicians can treat the following:
Flu Sore throat Headache Rash
Allergies Fever Nausea/vomiting Ear problems
Cough Sinus infection Pink eye UTI
STANDARD PLAN: ECONOMY PLAN:
$25 COPAY $35 COPAY
How to Get Started www.mdlive.com/bcbstx
To register, go to www.mdlive.com/bcbstx. Enter
your first and last name, date of birth, and BCBSTX
member ID number. Once you have an account, you 888-680-8646
can browse doctor profiles, view available
appointment times, and schedule an appointment
with the doctor of your choice. www.mdlive.com/getapp
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LIVONGO
DIABETES SUPPORT
The Simpler Way to a Healthier You
Testing and tracking your blood glucose levels is critical to successfully managing your diabetes, but it can be
a time-consuming, manual process. Now, there’s a better way! Livongo provides you with an advanced blood
glucose meter, unlimited test strips, and on-demand coaching anytime, 100% paid for by the Archdiocese of
Galveston-Houston.
Join Livongo and You’ll Get:
Reorder test strips right Real-time support from Personalized tips with
from your meter coaches when you need it each blood glucose check
Send health summary
Automatic uploads mean Optional family alerts keep
reports to your doctor
no more logbooks everyone in the loop
directly from your meter
A more helpful meter
Get advice on what to do next. Livongo’s meter gives you a personalized tip right after
each blood glucose check.
Unlimited test strips, no cost to you
With Livongo, test strips are ordered directly from your meter and delivered for free right
to your door.
Register at join.livongo.com/ARCHGH beginning January 1, 2021
or call 800-945-4355 with code: ARCHGH
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DENTAL
BENEFITS
Dental coverage is important to your overall health and wellness. Eligible employees can enroll in dental
benefits through Blue Cross Blue Shield of Texas (BCBSTX). The Dental PPO Plan helps you with the cost of
preventive, basic, and major dental services for yourself and your eligible dependents.
This plan gives you the freedom to select any dentist, but you will pay less out-of-pocket when you choose a
provider in the BCBSTX Dental Network. To find an in-network provider, go to www.bcbstx.com and click on
“Find a Doctor.” Next scroll to the bottom of the page and select “Find a Dentist.” Enter your search criteria to
find in-network dentists near you.
Dental Services Dental PPO Plan
BCBSTX Dental PPO Network In-Network and Out-of-Network
Annual Deductible $50 / $150
Individual / Family
Annual Benefit Maximum $1,500 per person
Diagnostic & Preventive Services Plan pays 100%; deductible waived
Exams, cleanings, bitewing x-rays, sealants
Basic Services You pay 20% after deductible
Endodontics, periodontics, root canals, oral surgery
Major Services You pay 50% after deductible
Crowns, inlays, onlays, prosthodontics, implants
Orthodontic Services You pay 50% after lifetime orthodontic deductible
Lifetime Orthodontic Deductible $50 per person
Lifetime Benefit Maximum $1,500 per person
Eligibility Adults & dependent children (up to age 19)
Out-of-Network Dental Claims
While benefits appear to be the same for in-network and out-of-network dentists, please remember that if you
choose an out-of-network dentist, there will be a maximum limit that BCBSTX will reimburse. If an out-of-
network provider charges over this amount, you may be balance billed by your dentist for the difference
between the provider’s charge and the maximum reimbursement allowed by the plan. Additionally, you must
file your own claim to be reimbursed for out-of-network services. You can find the claim form and instructions
posted under the “Forms” section of the Archdiocese of Galveston-Houston Human Resources website.
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VISION
BENEFITS
The Archdiocese of Galveston-Houston offers all eligible employees vision coverage through VSP. Eye care is a
vital component of a healthy lifestyle. Regular eye examinations can not only determine your need for
corrective eyewear but also may detect general health problems in their earliest stages. Your vision plan makes
regular exams and purchasing contacts or glasses simple and affordable.
With your vision coverage, you and your covered dependents have access to quality vision care. The plan uses
VSP’s network of vision care providers, including retail optical centers, optometrists, and opticians. Although
you can see any eye doctor you choose, you’ll save the most money if you choose an eye doctor from VSP’s
extensive network of providers. Your plan also offers special pricing for LASIK and PRK correction procedures
from contracted providers. To access a list of in-network providers and retail centers, or to see a list of
contracted LASIK and PRK correction providers, visit www.vsp.com or call 1-800-877-7195.
Vision Services Vision Plan
VSP Vision Network In-Network Out-of-Network
Eye Examinations $20 copay Reimbursed up to $50
Lenses
Single Vision $20 copay Reimbursed up to $50
Lined Bifocal $20 copay Reimbursed up to $75
Lined Trifocal $20 copay Reimbursed up to $100
Lenticular $20 copay Reimbursed up to $125
Photochromic/Transition $20 copay Reimbursed up to $5
*
Standard Progressive $20 copay Reimbursed up to $75
Frames $150 allowance Reimbursed up to $70
Elective Contact Lenses $150 allowance Reimbursed up to $105
Applies to materials and exam (fitting & evaluation)
Benefit Frequency
Examination Once every 12 months
Lenses OR Contact Lenses Once every 12 months
Frames Once every 12 months
* $80—$90 copay for Premium Progressive Lenses, $120—$160 copay for Custom Progressive Lenses. All out-of-network progressive lenses are reimbursed up to $75.
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2021 PAYROLL
DEDUCTIONS
Medical/Rx Rates
Biweekly Premium: Monthly Premium:
Standard Plan
Employee Only $0.00 $0.00
Employee + Spouse $210.46 $456.00
Employee + Child(ren) $161.54 $350.00
Employee + Family $263.08 $570.00
Economy Plan
Employee Only N/A N/A
Employee + Spouse $179.08 $388.00
Employee + Child(ren) $104.77 $227.00
Employee + Family $183.23 $397.00
Dental & Vision Rates
Biweekly Premium: Monthly Premium:
Dental Plan
Employee Only $0.00 $0.00
Employee + One Dependent $25.22 $54.65
Employee + Two or More Dependents $42.04 $91.08
Vision Plan
Employee Only $4.21 $9.13
Employee + One Dependent $6.08 $13.18
Employee + Two or More Dependents $11.72 $25.40
Supplemental Life Rates
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LIFE, AD&D
& DISABILITY
Life and AD&D
With Life and Accidental Death & Dismemberment (AD&D) insurance provided through The Standard, your
family will be protected with benefits and a variety of support services designed to help cope with both
emotional and financial issues. The Archdiocese of Galveston-Houston provides all eligible employees with
Basic Life and AD&D insurance at no cost to you, and you also have the option to purchase Supplemental Life
Insurance for yourself and your child(ren). Review the chart below for details.
Basic Life/AD&D Insurance Supplemental Life Insurance3
Lay & Religious Employees1 Lay & Religious Employees Child(ren) (live birth—age 26)
Benefit Amount 1.5x your annual earnings Increments of $25,000 $10,000
5x your annual earnings, not to
Maximum Benefit $50,000 $10,000
exceed $100,0004
To 67% at age 65 To 67% at age 65
Age Reduction Schedule N/A
To 50% at age 702 To 50% at age 705
Benefit Paid By Archdiocese of Galveston-Houston Employee Employee
(1) Active Seminarians receive a flat $5,000 Basic Life/AD&D benefit.
(2) Benefit reduces on January 1st following the date you attain age 65 and age 70.
(3) Spouse Supplemental Life Insurance is no longer offered as of 1/1/2016; however, spouses currently covered under the Spouse Life benefit are grandfathered, and rates will match the Supplemental
Life Insurance rates for Employees.
(4) If you are newly eligible, you may elect up to the guarantee issue amount without Evidence of Insurability (EOI). If you waived coverage when you were first eligible or were denied coverage, any amount
elected will be subject to EOI. If you currently have coverage, any increases in coverage will require EOI. Elections requiring EOI will not become effective until and unless approved by The Standard.
Keep Your Beneficiary Information Updated
When you enroll in benefits, you must designate a beneficiary
(the person who will receive the benefit) for your Life and AD&D
insurance. You may have both a primary and contingent
(secondary) beneficiary, as long as the total percentage adds up
to 100%. Annual enrollment is a great time to revisit your
beneficiary information. It is important to confirm that your
beneficiary information (i.e., address, Social Security Number,
date of birth) is correct. To update and/or confirm your
beneficiary information, please complete a beneficiary form and
submit it to Human Resources.
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Short-Term & Long-Term Disability
At no cost to the employee, Archdiocese of Galveston-Houston provides Short-Term Disability and Long-
Term Disability Insurance through The Standard for all eligible employees. Disability Insurance is designed to
replace a portion of your income when you are unable to work due to a covered, non work-related injury or
illness.
The eligible employee must file a claim with The Standard. Your physician will be required to certify your
disability and if qualified, The Standard will determine Short-Term Disability, Long-Term Disability, and Family
Medical Leave Act (FMLA) eligibility. Health and Dental benefits continue while on approved FMLA. ONCE AN
EMPLOYEE QUALIFIES FOR LONG-TERM DISABILITY, EMPLOYMENT AND ALL BENEFITS ARE TERMINATED.
Disability Benefits
Short-Term Disability (STD) Benefit Description
Weekly Benefit 60% of your pre-disability weekly salary
Elimination Period 14 days
Maximum Weekly Benefit $1,000
Maximum Benefit Duration 12 weeks
Long-Term Disability (LTD) Benefit Description
Monthly Benefit 60% of your pre-disability monthly salary
Elimination Period Later of 90 days or the end of the STD maximum benefit duration
Maximum Monthly Benefit $8,500
Maximum Benefit Duration Social Security Normal Retirement Age
Leaves of Absence
If you need to take a leave of absence from work, you can rest assured that you have protection. The Standard
will administer all leave requests for any of the following reasons:
Your own serious health condition Qualifying exigency when an immediate family
Caring for an immediate family member with a member is a military service member on covered
serious health condition active duty or has been notified of an impending call/
order to covered active duty status
The birth of a child
Caring for a covered military service member with a
Time to bond with a newborn or newly placed
serious injury or illness, to whom you are an
(adoption or foster care) child immediate family member or next of kin
Please contact The Standard 30 days prior to the last day you plan to work before taking your leave. If a
sudden event results in an unscheduled leave, please contact The Standard as soon as possible.
Need to file a disability claim or request a leave of absence?
Your group number is 756955.
www.standard.com/absence 1-833-229-4173
15 Archdiocese of Galveston-HoustonYour 2021 Medical Pharmacy Dental Vision Life, AD&D Additional
Benefits Benefits Benefits Benefits Benefits Disability Benefits
WORK-LIFE
BALANCE
Employee Assistance Program
We all experience times when we need a little help preparing for and dealing with the stresses of life. Your
Employee Assistance Program (EAP), which is provided to you at no additional cost, gives you, your
dependents, and all household members the ability to contact master’s-degreed clinicians 24/7 by phone,
online, live chat, email, and text. There’s even a mobile app for assistance on the go. Receive referrals to
support groups, a network counselor, community resources, or your health plan. If necessary, you’ll be
connected to emergency services.
Your Employee Assistance Program (EAP) includes up to 3 face-to-face counseling sessions per issue.
Assistance is immediate, personal, and available when you need it. EAP services can help you with:
Depression, grief, loss, and emotional wellbeing Financial and legal concerns
Family and relationship issues Identity theft and fraud resolution
Life improvement and goal setting Stress or anxiety with work or family
Addictions and substance abuse Online will preparation
To take advantage of the services available to you through your EAP, call 888-293-6948 (TTY 800-327-1833)
or visit www.workhealthlife.com/Standard3 to explore a wealth of information online, including videos, guides,
articles, webinars, resources, self-assessments and calculators. Morneau Shepell is the EAP vendor that The
Standard utilizes for Archdiocese of Galveston-Houston members.
Travel Assistance
You and your family can get support while traveling 100+ miles from home or
internationally, including passport, visa, weather and currency exchange
information, help replacing lost passports or credit cards, referrals to medical
providers, emergency medical evacuation, legal and interpreter services, and more!
Travel assistance is available worldwide 24/7.
In the US, Canada, Puerto Rico, USVI & Bermuda: 800-872-1414
Everywhere else: +1-609-986-1234 *Download the Mobile App
Text Message: +1-609-334-0807 by scanning the QR code
Email: medservices@assistamerica.com Reference Number: 01-AA-STD-5201
2021 Employee Benefits Guide 16Your 2021 Medical Pharmacy Dental Vision Life, AD&D Additional
Benefits Benefits Benefits Benefits Benefits Disability Benefits
Life Services Toolkit
The Standard offers a lineup of additional services that can make a difference to you and your loved ones both
now and in the future. Online tools and services can help you create a will, make advance funeral plans, and put
your finances in order. After a loss, your beneficiary can consult experts by phone or in person, and obtain
other helpful information online.
Services to Help You Now Services to Help Your Beneficiary
Estate Planning Assistance Grief Support
Online tools, found in the Legal Forms section of Clinicians with master’s degrees are on call to
the Life Services Toolkit website, walk you through provide confidential grief counseling sessions.
the steps to prepare a will and create other Your beneficiaries are eligible for up to 6 face-to-
documents such as living wills, powers of attorney face sessions and unlimited phone contact.
and health care agent forms. Financial Assistance
Financial Planning Your beneficiaries will have unlimited phone
Consult online services to help you manage debt, access to financial counselors who can help with
calculate mortgage and loan payments, and take issues such as budgeting, credit and debt
care of other financial matters with confidence. management and more.
Health and Wellness Legal Services
Access to timely articles about nutrition, stress Obtain an estate planning package that consists of
management and wellness help employees and a simple will, living will, health care agent form and
their families lead healthy lives. a durable power of attorney. Beneficiaries who
choose to retain a participating attorney after an
Identity Theft Prevention
initial consultation receive a 25% discount.
Check the Life Services Toolkit website for ways
to thwart identity thieves and resolve issues if Support Services
identity theft occurs. During an emotional time, your beneficiaries can
receive help planning a funeral or memorial
Funeral Arrangements
service. Advisors can guide them to resources to
Use the website to calculate funeral costs, find
help manage household repairs and chores, find
funeral-related services and make decisions
child care and elder care providers, or organize a
about funeral arrangements in advance.
move or relocation.
Take advantage of the helpful resources
available with your Life Services Toolkit
www.standard.com/mytoolkit
(username = assurance)
800-378-5742
17 Archdiocese of Galveston-HoustonYour 2021 Medical Pharmacy Dental Vision Life, AD&D Additional
Benefits Benefits Benefits Benefits Benefits Disability Benefits
Important Contacts
Benefit Vendor Phone Website/Email
Archdiocese of
Human Resources 713-652-8265 www.archgh.org
Galveston-Houston
Medical Blue Cross Blue Shield
800-521-2227 www.bcbstx.com
(Group #274679) of Texas (BCBSTX)
Prescription Drugs OptumRx 1-855-524-0381 www.optumrx.com
Virtual Visits MDLive 888-680-8646 www.mdlive.com/bcbstx
Blue Cross Blue Shield
Nurseline 800-581-0393 N/A
of Texas (BCBSTX)
Diabetes Support Livongo 800-945-4355 join.livongo.com/ARCHGH
(Registration Code: ARCHGH)
Dental Blue Cross Blue Shield
800-521-0393 www.bcbstx.com
(Group #274852) of Texas (BCBSTX)
Vision VSP 1-800-877-7195 www.vsp.com
(Group #12001362)
Life and AD&D The Standard 1-833-229-4173 www.standard.com
(Group #756955)
Disability & Leave
Management The Standard 1-833-229-4173 www.standard.com/absence
(Group #756955)
Employee Assistance The Standard 888-293-6948
Program www.workhealthlife.com/Standard3
(Morneau Shepell) TTY: 800-327-1833
(Group #756955)
USA, Canada, Puerto Rico, USVI medservices@assistamerica.com
The Standard & Bermuda: 800-872-1414 Reference Number: 01-AA-STD-5201
Travel Assistance
(Assist America) Worldwide: +1-609-986-1234 Download the Assist America Mobile
Text: +1-609-334-0807 App on the App Store or Google Play
www.standard.com/mytoolkit
Life Services Toolkit The Standard 800-378-5742
Username: assurance
The Archdiocese of
Benefits Help Line 855-664-8164 agh_benefits@ajg.com
Galveston-Houston
Know Your Numbers
Use the space below to write in your identification number
(located on the front of your BCBSTX ID card)
Identification Number:
Medical Group Number: 274679
Dental Group Number: 274852
2021 Employee Benefits Guide 18This benefits guide prepared by This Employee Benefits Guide highlights recent plan design changes and is intended to fully comply with the requirements of a self-funded Church Plan Sponsor as a Summary of Material Modifications and should be kept with your most recent Summary Plan Description. This document is an outline of the coverage proposed by the carrier(s), based on information provided by your company. It does not include all of the terms, coverage, exclusions, limitations and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area. The Archdiocese of Galveston-Houston believes its Medical and Pharmacy Plan as described in this guide is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan must preserve certain basic health coverage that was already in the Plan when that law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections (health and pharmaceutical coverages) of PPACA that apply to other (non-grandfathered) plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, the grandfathered plans must comply with certain other consumer protections in PPACA, for example, the elimination of lifetime limits on benefits. As a grandfathered plan, this Plan, self-funded by the Archdiocese of Galveston-Houston, does not provide medical and pharmaceutical coverage that contravenes with Catholic teachings. Questions regarding which protections (Medical and Pharmaceutical coverages) apply and which protections (Medical and Pharmaceutical coverages) do not apply to our grandfathered health plan status can be directed to the plan administrator, Charlie Pavlovsky, at 713-652-8261.
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