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Table of Contents How to Enroll Disclaimers Rate Sheet Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) Medical Health Savings Account (HSA) Hospital Indemnity Telehealth Dental Vision Disability Life and AD&D Individual Life Medical Transport Cancer Accident Critical Illness Identity Theft Flexible Spending Account (FSA) 2

3 4 5-11 12-17 12 13 14 15 16

FLIP TO... PG. 3


PG. 12


PG. 18



18 18 19 19 20 20 21 21 22 22 23 23 24 24 25

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Access to everything you need to complete your benefits enrollment: • Mobile App • Online Support • Interactive Tools • And more.

Text “FBS WTX” to 313131 OR SCAN

How to Log In







Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. If you have six (6) or less characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: Last Name (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.



Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the WTXEBC Benefits Website. This summary does not replace or amend the underlying plan documentation. In the event of a discrepancy between this summary and the plan documentation the plan documentation governs. All plans and benefits described in this summary may be discontinued, increased, decreased, or altered at any time with or without notice.

Rate Sheet General Disclaimer: The rate information provided in this guide is subject to change at any time by your employer and/or the plan provider. The rate information included herein, does not guarantee coverage or change or otherwise interpret the terms of the specific plan documentation, available at WTXEBC Benefits Website, which may include additional exclusions and limitations and may require an application for coverage to determine eligibility for the health benefit plan. To the extent the information provided in this summary is inconsistent with the specific plan documentation, the provisions of the specific plan documentation will govern in all cases.


Rate Sheet Dental*

TRS Medical* Monthly Premium without district contributions ActiveCare 1-HD Employee Only Employee & Spouse Employee & Children Employee & Family

$378 $1,066 $722 $1,425 ActiveCare Select

Employee Only Employee & Spouse Employee & Children Employee & Family

$556 $1,367 $902 $1,718 ActiveCare 2

Employee Only Employee & Spouse Employee & Children Employee & Family

$560.50 $1,416.52 $892.16 $1,454.80

FSA Maximum Contribution Healthcare Dependent Care

Low $19.14 $36.66 $46.51 $64.13

High $33.21 $63.49 $80.85 $111.22

Vision* Employee Only Employee and Spouse Employee and Child Employee and Family

$7.80 $15.46 $15.17 $22.95

Voluntary Life and AD&D (per $10,000) $852 $2,020 $1,267 $2,389

FirstCare Employee Only Employee & Spouse Employee & Children Employee & Family

Employee Only Employee and Spouse Employee and Child Employee and Family

$2,700.00 $5,000.00

HSA Maximum Contribution Individual $3,500.00 Family $7,000.00 Not all districts within the WTXEBC offer this benefit.

Employee Age Employee & Spouse <24 $0.54 25-29 $0.54 30-34 $0.72 35-39 $0.81 40-44 $0.99 45-49 $1.53 50-54 $2.88 55-59 $4.95 60-64 $7.92 65-69 $11.04 70-74 $18.54 75+ $18.54 Child Life monthly rate is $1.00 per $5,000. One life premium covers all children

AD&D (per $10,000) Employee Employee + Family

$0.40 $0.70

Hospital Indemnity Emergency Transportation Employee & Family


* Rates may vary for this product due to each employerâ&#x20AC;&#x2122;s contribution amount. Please contact your benefit administrator to confirm rates for your school.

Employee Only Employee & Spouse Employee & Children Employee & Family

Option 1

Option 2

$21.47 $43.17 $30.71 $50.12

$37.36 $75.46 $53.40 $87.33 5

Rate Sheet Critical Illness Age Band


20-24 25-29


35-39 40-44 45-49







$10,000 Employee Only


$1.16 $1.20









Employee + Spouse


$1.97 $2.17




$6.86 $10.84 $16.00




Employee + Child(ren) $0.93

$1.16 $1.20









Employee + Family

$1.97 $2.17




$6.86 $10.84 $16.00






$20,000 Employee Only


$2.32 $2.40




$7.10 $12.29 $19.12




Employee + Spouse


$3.93 $4.34



$9.79 $13.71 $21.68 $32.01




Employee + Child(ren) $1.87

$2.32 $2.40




$7.10 $12.29 $19.12




Employee + Family

$3.93 $4.34



$9.79 $13.71 $21.68 $32.01



$84.97 $87.95


$30,000 Employee Only


$3.48 $3.61


$8.45 $10.65 $18.43 $28.68



Employee + Spouse


$5.90 $6.51

$8.11 $10.57 $14.68 $20.57 $32.52 $48.01


$94.03 $127.46

Employee + Child(ren) $2.80

$3.48 $3.61


$8.45 $10.65 $18.43 $28.68



Employee + Family

$5.90 $6.51

$8.11 $10.57 $14.68 $20.57 $32.52 $48.01


$94.03 $127.46


$6.17 $6.17


*Rates are based on your (the subscribers) current age but will increase as you move into a higher age band.

Cancer Monthly Rates

Base Plan A

Base Plan B

Base Plan C

Employee Single Parent Employee & Spouse Family

$19.74 $24.12 $33.18 $33.18

$25.14 $30.32 $41.85 $41.85

$35.89 $42.65 $59.40 $59.40


Base Plan A with Base Plan B with Base Plan C with ICU ICU ICU $22.06 $27.46 $38.21 $27.31 $33.52 $45.84 $37.58 $46.25 $63.80 $37.58 $46.25 $63.80

Identity Theft Protection

Level 11 Unit

Level 22 Units

Level 33 Units

Level 44 Units






Individual + Spouse





1 Parent Family





2 Parent Family





Employee Only


Employee & Family


Telehealth* Employee & Family


 Rates may vary for this product due to each employer’s contribution amount. Please contact your benefit administrator to confirm rates for your school. 6

Rate Sheet Long Term Disability Annual Earnings $3,600

Plan A Monthly Earnings $300

Accident/Sickness Elimination period in days Monthly Benefit $200

$5,400 $7,200 $9,000 $10,800 $12,600 $14,400

$450 $600 $750 $900 $1,050 $1,200

$300 $400 $500 $600 $700 $800

$16,200 $18,000 $19,800 $21,600 $23,400 $25,200

$1,350 $1,500 $1,650 $1,800 $1,950 $2,100

$900 $1,000 $1,100 $1,200 $1,300 $1,400

Annual Earnings $3,600 $5,400

Plan B Monthly Earnings $300 $450

Monthly Benefit $200 $300

$7,200 $9,000

$600 $750

$400 $500

$10,800 $12,600

$900 $1,050

$600 $700

$14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200

$1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100

$800 $900 $1,000 $1,100 $1,200 $1,300 $1,400







$6.06 $9.09 $12.12 $15.15 $18.18 $21.21 $24.24 $27.27 $30.30 $33.33 $36.36 $39.39 $42.42

$4.84 $7.26 $9.68 $12.10 $14.52 $16.94 $19.36 $21.78 $24.20 $26.62 $29.04 $31.46 $33.88

$4.00 $6.00 $8.00 $10.00 $12.00 $14.00 $16.00 $18.00 $20.00 $22.00 $24.00 $26.00 $28.00

$2.74 $4.11 $5.48 $6.85 $8.22 $9.59 $10.96 $12.33 $13.70 $15.07 $16.44 $17.81 $19.18

$2.36 $3.54 $4.72 $5.90 $7.08 $8.26 $9.44 $10.62 $11.80 $12.98 $14.16 $15.34 $16.52

$1.82 $2.73 $3.64 $4.55 $5.46 $6.37 $7.28 $8.19 $9.10 $10.01 $10.92 $11.83 $12.74

Accident/Sickness Elimination period in days 0/7






$4.66 $6.99 $9.32 $11.65 $13.98 $16.31 $18.64 $20.97 $23.30 $25.63 $27.96 $30.29 $32.62

$3.58 $5.37 $7.16 $8.95 $10.74 $12.53 $14.32 $16.11 $17.90 $19.69 $21.48 $23.27 $25.06

$2.66 $3.99 $5.32 $6.65 $7.98 $9.31 $10.64 $11.97 $13.30 $14.63 $15.96 $17.29 $18.62

$1.54 $2.31 $3.08 $3.85 $4.62 $5.39 $6.16 $6.93 $7.70 $8.47 $9.24 $10.01 $10.78

$1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $4.80 $5.40 $6.00 $6.60 $7.20 $7.80 $8.40

$0.84 $1.26 $1.68 $2.10 $2.52 $2.94 $3.36 $3.78 $4.20 $4.62 $5.04 $5.46 $5.88


2019 – 20 TRS-ActiveCare Plan Highlights Effective Sept. 1, 2019 through Aug. 31, 2020 | In-Network Level of Benefits1 TRS-ActiveCare 1-HD

TRS-ActiveCare Select or TRS-ActiveCare Select Whole Health

TRS-ActiveCare 2

(Baptist Health System and HealthTexas Medical Group; Baylor Scott and White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)

NOTE: If you’re currently enrolled in TRSActiveCare 2, you can remain in this plan. However, as of Sept. 1, 2018, TRS-ActiveCare 2 is closed to new enrollees.

$500 copay per visit plus 20% after deductible

$500 copay per visit plus 20% after deductible

Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible)

Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays Preventive Care See below for examples Teladoc® Physician Services

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital Facility Charges Only (preauthorization required) In-Network


Urgent Care Freestanding Emergency Room Participant pays

$500 copay per visit plus 20% after deductible

Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery (only covered if performed at an 10Q facility) Physician charges; Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist)Participant pays Annual Hearing Examination Participant pays Preventive Care Some examples of preventive care frequency and services: • • • •

Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smoking cessation counseling – 8 visits per 12 months Well-child care – unlimited up to age 12

• • •

Colonoscopy – one every 10 years age 50 and over Healthy diet/obesity counseling – unlimited to age 22; age 22 and over – 26 visits per 12 months Well woman exam & pap smear – annually age 18 and over

• •

Prostate cancer screening – one per year age 50 and over Breastfeeding support – six lactation counseling visits per 12 months

Note: Covered services under this benefit must be billed by the provider as “preventive care.” Non-network preventive care is not paid at 100%. If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the TRS-ActiveCare 1-HD and TRS-ActiveCare 2. There is no coverage for non-network services under the TRS-ActiveCare Select plan or TRS-ActiveCare Select Whole Health. For more information, please view the Benefits Booklet at www.trsactivecareaetna.com. TRS-ActiveCare is8 administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark

2019 – 20 TRS-ActiveCare Plan Highlights TRS-ActiveCare 1-HD

TRS-ActiveCare Select or ActiveCare Select Whole Health

TRS- ActiveCare 2

(Baptist Health System and HealthTexas Medical Group; Baylor Scott and White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)

NOTE: If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan. However, as of Sept. 1, 2018, TRS-ActiveCare 2 is closed to new enrollees.

Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after deductible, except for certain generic preventive $15 copay drugs that are covered at 100%.2 25% coinsurance after deductible3 25% coinsurance (min. $404; max. $80)3 50% coinsurance after deductible3 50% coinsurance3 Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)5 20% coinsurance after deductible $45 copay 25% coinsurance after deductible3 25% coinsurance (min. $1054; max. $210)3 3 50% coinsurance after deductible 50% coinsurance3 Specialty Medications (up to a 31-day supply)

$20 copay 25% coinsurance (min. $404; max. $80)3 50% coinsurance (min. $1004; max. $200)3 $45 copay 25% coinsurance (min. $1054; max. $210)3 50% coinsurance (min. $2154; max. $430)3

20% coinsurance (min. $2004 , max $900)

Specialty Medications

20% coinsurance after deductible 20% coinsurance Short-Term Supply of a Maintenance Medication at Retail Location up to a 31-day supply

The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy, they will be charged the coinsurance and copays in the rows below. Participants can save more over the plan year by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location.

Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand

20% coinsurance after deductible 25% coinsurance after deductible3 50% coinsurance after deductible3

$30 copay 25% coinsurance (min. $604; max. $120)3 50% coinsurance3

$35 copay 25% coinsurance (min. $604; max. $120)3 50% coinsurance (min. $1054; max. $210)3

What is a maintenance medication? Maintenance medications are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $15, then you will pay $30 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $180 over the year by filling a 90 -day supply.

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the TRS-ActiveCare Select or TRS-ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. 2 For TRS-ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 – individual, $5,500 – family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.

Monthly Premiums

Full monthly premium *

Premium with min. state/ district contribution**


+Spouse +Children



Your Monthly Premium***

Full monthly premium *

Premium with min. state/ district contribution **









Your Monthly Premium***

Full monthly premium *

Premium with min. state/ district contribution **
















Your Monthly Premium***

* If you are not eligible for the state/district subsidy, you will pay the full monthly premium. Please contact your Benefits Administrator for your monthly premium. ** The premium after state, $75 and district, $150 contribution is the maximum you may pay per month. Ask your Benefits Administrator for your monthly cost. (This is the amount you will owe each month after all available subsidies are applied to your premium.) *** Completed by your benefits administrator. The state/district contribution may be greater than $225. 9

2019-2020 TRS-FirstCare Plan Highlights Plan Summary 2019 -2020 Medical Plan Year Deductible Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) Annual Maximum

$950 Individual; $2,850 Family $7,450 Individual; $14,900 Family Unlimited

Primary Care Provider (PCP) Office Visit • Includes routine lab/X-ray services, injectables, and supplies • Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$20 copayment

PCP Office Visit-Dependents, through age 19

$0 copayment

Specialist Office Visit • Includes routine lab/X-ray services • Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$70 copayment

Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening

No copayment

Surgical Procedures Performed in the Physician's Office Urgent Care

25% coinsurance1 $50 copayment

Emergency Room

$500 copayment1

Ambulance Air/Ground

25% coinsurance1

Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility, behavioral health (mental health/chemical dependency)

25% coinsurance1

Outpatient Services Facility charges, physician services, surgical procedures, observation unit

25% coinsurance1

MRI, CT Scan, PET Scan (Facility/Physician)

$250 copayment1

Diagnostic Tests Sleep study; Stress test; EKG; Ultrasound; Cardiac imaging; Genetic testing; Non-preventive Colonoscopy (Facility/Physician)

25% coinsurance1

Home Health Care Limited to 60 visits per plan year

25% coinsurance1

Hospice Care

25% coinsurance1

Skilled Nursing Facility Limited to 30 days per plan year

25% coinsurance1

Accidental Dental Care

25% coinsurance1

Durable Medical Equipment

25% coinsurance1

All Other Covered Services

25% coinsurance1


Prescription Drug Plan Year Deductible

$150 Per Individual

Participating Retail Pharmacy (Standard drugs/30-day supply) • ACA Preventative • Preferred Generic • Preferred Brand • Non-preferred Brand/Non-preferred Generics • Specialty Medications Tier 1 and 2 Tier 3

$0 copayment $5 copayment 30% coinsurance2 50% coinsurance2

15% coinsurance2 25% coinsurance2

Maintenance (up to 90-day supply at BSW pharmacies, in-network retail, and mail order for maintenance eligible drugs) • • • • 1 2

$0 copayment $12.50 copayment 30% coinsurance2 50% coinsurance2

ACA Preventative Preferred Generic Preferred Brand Non-preferred Brand/Non-preferred Generics

Subject to medical deductible Subject to prescription drug deductible

Gross Monthly Cost for Coverage Effective September 1, 2019 - August 31, 2020 Coverage Category Employee only Employee and spouse Employee and child(ren) Employee and family

Total Cost* $560.50 $1,416.52 $892.16 $1,454.80

*District and state funds are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.


Annual Benefit Enrollment


Benefit Updates - What’s New: •

NEW HOSPITAL INDEMNITY PLAN! While medical plans typically cover hospitalization, they don’t cover everything. This plan can help you and your family with out of pocket costs associated with an inpatient hospital stay. If the hospital admits you, you will get a lump-sum payment (up to $2,500), a per-day payment, and an additional per-day payment for an ICU stay (up to $250/day). Carrier pays plan members directly, by check, and claims can be filed online. If you are a TRS Medical member, you don’t need to submit any additional supporting paperwork to get paid. Coverage is guaranteed issue, meaning you can never be turned away for prior health problems. HEALTH SAVINGS ACCOUNT (H.S.A.) Your school district may offer employees who are enrolled in a high deductible health care plan the opportunity to contribute to an HSA to pay for eligible medical, dental and vision expenses. This year, all HSA’s are being administered by a new carrier. Individual maximum contribution is $3,500 and Family maximum contribution is $7,000 per year. If you are actively participating in a HSA your FSA will be limited to only dental and vision. Make sure to login and complete a walkthrough if you are wanting this benefit for the 2019-2020 plan year, it is not automatically renewed. An employee and a spouse may both contribute to their own Health Savings Account, but their combined total can not exceed the family maximum in any given tax year. • •

• •

NEW CRITICAL ILLNESS CARRIER! Critical Illness provides a lump-sum cash benefit to pay for medical and personal expenses. The plan pays out when you are diagnosed with a range of serious medical conditions like a heart attack, stroke, major organ failure, paralysis, coma and many more. Plan options include up to $30,000 and you can cover your family members at half of your benefit amount.

FLEXIBLE SPENDING ACCOUNTS (FSA) Tax sheltered flexible spending accounts allow an individual to set aside dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year (9/01/19 to 8/31/20) and contributions are “use it or lose it.” Participating employees will receive a FSA MasterCard with your entire annual FSA contribution to spend throughout the entire school year. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app, or you call 855-399-3035 and speak to a representative. You MUST RE-ELECT this benefit each year.

Login and complete your benefit enrollment from 07/22/19 - 08/23/2019 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 Monday-Thursday 8am – 5:30pm CST, Friday 8am – 3pm CST. Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers



Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.


Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in Status of Employment Affecting Coverage Eligibility

Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.

Gain/Loss of Dependents' Eligibility Status

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent status.


If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.

Eligibility for Government Programs

Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.



Annual Enrollment During your annual enrollment period, you have the opportunity

Where can I find forms?

to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of

For benefit summaries and claim forms, go to the WTXEBC benefit website: www.wtxebc.com. Click on your school

annual enrollment) unless a Section 125 qualifying event occurs.

district, then click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under

the Benefits and Forms section.

Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.

How can I find a Network Provider?

• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.

Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.

For benefit summaries and claim forms, go to the WTXEBC benefit website: www.wtxebc.com. Click on your school district, then click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the

insurance company’s phone number and they can call and

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this

timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your

Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.


verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no

changes to the plan, you typically will not receive a new ID card each year.


Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of

covered by married spouses within WTXEBC or as both employees and dependents.

work concurrent with the plan effective date. For example, if your 2019 benefits become effective on September 1, 2019, you must be actively-at-work on September 1, 2019 to be eligible for your new benefits. PLAN



Through 25


Through 24

Critical Illness

Through 25


Through 25

Dependent Flex

12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes

Family Protection Plan w/ QOL Rider

Issue through 23; Keep to 100

Healthcare FSA

Through 25 or IRS Tax Dependent

Health Savings Account

IRS Tax Dependent

Identity Theft

Through 25

Medical Supplement Plan

Through 25


Through 25


Through 25

Voluntary Life and AD&D

Through 25

Medical Transportation

Through 25

If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physicianâ&#x20AC;&#x2122;s statement confirming your dependentâ&#x20AC;&#x2122;s disability. Contact your HR/Benefit Administrator to request a continuation of coverage. 15

Helpful Definitions


Actively at Work


You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual

Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2019 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.

Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.

Calendar Year January 1st through December 31st

Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.


Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.

Plan Year September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).


HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)

Flexible Spending Account (FSA) (IRC Sec. 125)


Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.

Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care tax-free.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee and/or employer

Employee and/or employer

Account Owner



Underlying Insurance Requirement

High deductible health plan


Minimum Deductible

$1,350 single (2019) $2,700 family (2019)


Maximum Contribution

$3,500 single (2019) $7,000 family (2019)


Permissible Use Of Funds

Cash-Outs of Unused Amounts (if no medical expenses)

If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty. Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC). Not permitted

Year-to-year rollover of account balance?

Yes, will roll over to use for subsequent year’s health coverage.

No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?




Yes, portable year-to-year and between jobs.



You will only have access to HSA funds that have been contributed up to that point. HSAs are not front loaded.

You will have access to the entire annual contribution amount on the effective date of your FSA. FSA balance is front loaded to provide access to the entire annual contribution.


About Medical Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Medical Insurance Healthcare is one of the few things that people purchase and never know the true cost or value. If we knew the typical cost of common medical services. We would realize how much we save by opting into a major medical plan. The average 30-day prescription for a name brand is $945.98. For a generic prescription, it is $67.61. An average emergency room visit without insurance is $1,283.

60% of adults across the United States have a chronic disease.

A Well Baby Visit typically costs $204 and a regular delivery is $10,273.

Certain preventative care services are covered at 100% in-network.

https://www.cdc.gov/chronicdisease/resources/ infographic/chronic-diseases.htm

About HSA A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used. Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP). For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need an HSA Healthcare Savings Accounts are designed to work in conjunction with high deductible health plans (HDHPs) to help cover the rising costs of healthcare. HSA funds accrue interest over time tax-free with no lifetime limit. HSA accounts are individual accounts. Contributions are yours to keep even if you leave your employer.

HSA funds can be used to pay for any qualified medical expense for you and your tax-eligible dependents, even if the expense is not covered by your insurance plan. 18

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income. https://www.irs.gov/publications/p969 https://www.irs.gov/pub/irs-pdf/p969.pdf

About Hospital Indemnity This is an affordable supplemental plan that pays you should you be in-patient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need a Hospital Indemnity Plan

The median hospital cost has grown to over $10,500 per stay.

Hospital indemnity policies pay a set benefit based on your hospital stay. These funds: Help cover high medical deductibles and copays.







Provide a safety net for unexpected medical expenses. Can be paid directly to you or the care provider.

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb180Hospitalizations-United-States-2012.pdf https://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most -Expensive-Hospital-Conditions.jsp

About Telehealth Telehealth provides 24/7/365 access to board-certified doctors via telephone or video consultations that can diagnose, recommend treatment and prescribe medication. Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available. For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Telehealth Healthcare should be simple, fast, and effective. Telehealth makes it easy to get treatment for your minor ailments without visiting urgent care or your primary care physician.


Virtual visits can treat mild conditions like sinus infections, allergies, and pink eye without waiting on the next available appointment. No consultation fees on most plans.

Appointments while at work or traveling.

of all doctor, urgent care, and ER visits could be handled safely and effectively via telehealth. http://pages.healthcareitnews.com/rs/922-ZLW292/images/How%20To%20Successfully% 20Adopt%20Telemedicine%20Into%20Your% 20Practice_0.pdf?aliId=913083420


About Dental Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and disease.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Dental Insurance By opting into dental insurance, a person can save thousands of dollars per year on routine and emergency oral care. Average costs of dental procedures without insurance include: Office visits =$288

Good dental care may improve your overall health.

Cavity filling= $90-$250 Tooth Extraction= $75-$300

Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby. https://jada.ada.org/article/S0002-8177(17)30399-9/pdf https://www.colgate.com/en-us/oral-health/life-stages/oralcare-during-pregnancy/pregnancy-oral-health-and-yourbaby

About Vision Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Vision Insurance Vision insurance reduces the costs of services and products such as vision exams, glasses, frames, and contact lens. Regular eye exams can help detect other health issues such as diabetes, cancer, liver disease, and heart disease. Signs you need an eye exam include squinting, blurred vision, night vision issues, or chronic itching and redness.


76% of adults use some sort of vision correction. https://www.thevisioncouncil.org/sites/default/files/ Q415-Topline-Overview-Presentation-Stats-withNotes-FINAL.PDF

About Disability Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Disability Insurance On top of the medical bills that come with a serious injury or illness, can you afford to be out of work for an extended period of time? Disability insurance can offer you peace of mind to protect your paycheck. One in 8 workers will be disabled for 5 or more years during their working careers. A disabling injury occurs every eight seconds. Americans have a 50% chance of becoming disabled for 90 days or more between the ages of 35 and 65.

Just over 1 in 4 of today's 20 year-olds will become disabled before they retire.

34.6 months is the duration of the average disability claim. https://www.ssa.gov/disabilityfacts/facts.html


About Life and AD&D Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered. For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Life and AD&D Life insurance is never fun to think about and may seem like an unnecessary expense. However, if you have someone that depends on you financially, life insurance is really about protecting them if something were to happen to you. Life insurance and AD&D policies help your loved ones pay for expenses, such as:

Motor vehicle crashes

Mortgage payments College tuition Burial expenses

are one of the top causes of accidental deaths in the US including falls and poisoning.



About Individual Life Individual insurance is a policy that covers a single person and is intended to meet the financial needs of the beneficiary, in the event of the insuredâ&#x20AC;&#x2122;s death. This coverage is portable and can continue after you leave employment or retire.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Individual Life

Experts recommend at least

Individual life polices are owned by you and can be taken with you if you leave your employer and kept into retirement. These policies help protect loved ones from financial distress when you are gone.

x 10

Premiums are paid through your payroll deductions as long as you are with your employer. Premiums are based on coverage amount and age at time of purchase.

your gross annual income in coverage when purchasing life insurance. https://money.cnn.com/retirement/guide/ insurance_life.moneymag/index11.htm

About Medical Transport Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out -of-pocket costs that are not covered by insurance. It can include emergency transportation via ground ambulance, air ambulance and helicopter, depending on the plan.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Emergency Transportation Emergency transportation is one of the more expensive items in emergency medical care. Benefits of a medical transportation plan include: No cost emergency transportation for covered individuals. Coverage anywhere in the US and Canada. Some plans include worldwide coverage.

Coverage for both ground and air transportation.

A ground ambulance can cost up to


and a helicopter transportation fee can cost over $30,000 https://www.gao.gov/assets/650/649018.pdf https://www.gao.gov/assets/690/686167.pdf


About Cancer Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Cancer Insurance

Breast Cancer is the most commonly diagnosed cancer in women.

Cancer kills more than 500,000 Americans each year, making it the second most common cause of death in the United States. Cancer insurance is designed to relieve your financial burden to help you focus on recovering your health. Money received from cancer benefits can help pay for many expenses such as:

If caught early, prostate cancer is one of the most treatable malignancies.

Experimental cancer treatments Travel and lodging costs related to treatment Routine living expenses like mortgage and utility bills

https://www.cancer.org/cancer/breast-cancer/about/ how-common-is-breast-cancer.htm https://www.medicalnewstoday.com/ articles/322700.php

About Accident Do you have kids playing sports, are you a weekend warrior, or maybe accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Accident Insurance


More than of all medically consulted injuries in the US happen at home.

Accident insurance will deliver a pre-determined payment to you for various qualifying incidents. These occurrences may include: Injuries such as fractures, dislocations, burns, concussions, lacerations, etc. Medical services and treatments such as emergency transportation and physical therapy. Some plans also include accidental death and dismemberment or common carrier benefits as an add on benefit.


of American workers live paycheck to paycheck to maintain their livelihood.

https://injuryfacts.nsc.org/all-injuries/overview/ http://press.careerbuilder.com/2017-08-24-LivingPaycheck-to-Paycheck-is-a-Way-of-Life-for-Majority -of-U-S-Workers-According-to-New-CareerBuilderSurvey 23

About Critical Illness Critical illness insurance can be used towards medical or other expenses. It provides a lump sum benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke. The money can also be used for non-medical costs related to the illness, including transportation, child care, etc.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Critical Illness Insurance Serious medical conditions can affect not only your heath, but also your bank account. Medical expenses reportedly lead to more than half of all bankruptcies in the United States. When faced with a severe illness, a critical illness policy can help in many ways. Plans are designed to pay a benefit specific to the diagnosis usually ranging from $10,000 to $30,000. Plans often include a wellness benefit that pays employees for having certain annual screenings performed. Critical illness plans complement high deductible health plans (HDHP) by reducing the worry of having to pay a large medical deductible while suffering from a major illness.

$20,000 Is the average cost of a hospital stay for a heart attack. https://www.healthline.com/health-news/how-muchdoes-hospital-stay-cost#2

About Identity Theft Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need Identity Theft Protection ID theft helps you recover your identity in many ways. Your plan includes: Monitoring of your personal information 24/7/365. System alerts to inform you of potential threats. Works on your behalf to restore your identity.

An identity is stolen every 2 seconds, and an average of

30 hours

to resolve, causing an average loss of $500.

Peace of mind should a breach occur.


https://money.cnn.com/2014/02/06/pf/identity-fraud/ index.html https://www.ftc.gov/sites/default/files/documents/ reports/federal-trade-commission-identity-theftprogram/synovatereport.pdf

About FSA A Flexible Spending Account allows you to pay for eligible healthcare expenses with a pre-loaded debit card. You choose the amount to set aside from your paycheck every plan year, based on your employerâ&#x20AC;&#x2122;s annual plan limit. This money is use it or lose it within the plan year (unless your plan contains a $500 rollover or grace period provision). For full plan details, please visit your benefit website: www.wtxebc.com

Why I Need an FSA Your Flexible Spending Account saves you money by putting aside funds tax-free that can be used to pay for qualified medical expenses. Your pre-loaded FSA debit card can be used at places like the doctorâ&#x20AC;&#x2122;s office or the pharmacy without the need for reimbursement forms. You do not have to be enrolled in a medical plan to enroll in an FSA.

The funds in a full-purpose healthcare FSA can be used to pay for eligible medical expenses like deductibles, copayments, prescription drugs, orthodontics, glasses and contacts for you and any tax-eligible dependents.

http://www.hr.emory.edu/eu/benefits/tecbenefits/fsa/ about.html

For full details on all your benefits, please visit your benefit website: www.wtxebc.com 25






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2019 WTXEBC Benefit Guide  

2019 WTXEBC Benefit Guide