QUALIFYING EVENT AND MORE IMPORTANT INFORMATION
AKING CHANGES DURING THE YEAR
• A change in your marital status (marriage, divorce, legal separation)
• Birth, adoption, or obtaining legal guardianship of a dependent
• Death of spouse or dependent
• Changes in employment status/insurance coverage for spouse or dependent
• A change in job and/or leave status for an employee
• Medicaid or CHIP Eligibility Change
NEW EMPLOYEES
New employees must enroll within 30 days of their hire date. If employees fail to enroll with the 30 days, all benefits will be waived, and employees will be unable to enroll in coverage until the annual enrollment. With the exception of health insurance, plans will be effective on the first of the month following the date of hire. Health insurance can be effective on the date of hire OR the first of the month following the date of hire. Please be aware that if you choose the date of hire as the effective date for health insurance, you will be charges 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 U.S. Employee Benefits immediately at (830) 606-5100. Discrepancies must be identified within the first 30 days from the effective date of the policy to be considered.
BENEFIT RELATED DOCUMENTS
For carrier contact information, claim forms, benefit brochures, and more, please visit: www.mybenefits.hub.com/sanmarcoscisd
Login Process
www.mybenefitshub.com/sanmarcoscisd.
On the login page, you will enter your Last Name, Date of Birth, and Last Four (4) of Social Security Number.
THEbenefitsHUB checks behind the scenes to confirm employment status.
Once confirmed, the Additional Security Verification page will list the contact options from your profile.
Select either Text, Email, Call, or Ask Admin options to get a code to complete the final verification step.
Enter the code that you receive and click Verify.
You can now complete your benefits enrollment!
LEAVE OF ABSENCE
FMLA Eligibility Requirements: Employed with the District for 12 months and worked a total of 1250 hours.
Any full-time employee whose position requires certification from the State Board for Educator Certification (SBEC) is eligible for Temporary Disability Leave (TDL).
Both FMLA and TDL run concurrently together.
TDL runs on calendar days. FMLA applies to working days.
FMLA and TDL are unpaid leaves. You will be paid for the amount of time that you have paid leave for (Sick Leave, State Personal Leave, etc…).
Paid leave days start on your first day out and run until they are used up. Once they are used, you will be on an unpaid status.
STANDARD DISABILITY
Optional Insurance to Purchase
Must enroll for plan during Open Enrollment period.
May be a waiting period before benefits are payable.
Benefits are paid directly to the employee by disability insurance provider.
First Day Hospitalization Benefit: With this benefit, if an insured employee is hospital confined for at least four hours, is admitted as an inpatient and is charged room and board during benefit waiting period, the benefit waiting period will be satisfied. Benefits become payable on the date of hospitalization: the maximum benefit period also begins on that date. THIS FEATURE IS INCLUDED ONLY ON LTD PLANS WITH BENEFIT WAITIING PERIODS OF 30 DAYS OR LESS.
IMPORTANT
Your newbornchildis not automatically covered on your plan. You must add your baby to your insurance plan withinthe first 31 days of the child’sbirth. If you missthedeadline, you will have to wait until the next Open Enrollment period to add your childto your Districtinsurance plan effective thefollowing September 1st.
All other Qualifying Event Changes will need to be made within 30 days of the event.
Achange in marital status
Birth,adoption, or obtaining legal guardianship
Death of a spouse or dependent
Changes in employment status for spouse/dependent
Changeininsurance coverage for spouse/dependent
Medicaid or CHIP EligibilityChange
You must submit your benefit changes requests andinclude requiredsupporting documentation within 30 days of the qualifying event. As per IRS, only changes consistentthe qualifyinglife event willbeallowed
Learn the 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.
• Copay: The set amount you pay for a covered service at the time you receive it. The amount can vary based on the service.
• Coinsurance: The portion you’re required to pay for services after you meet your deductible. It’s often a specified percentage of the costs; e.g., you pay 20% while the health care plan pays 80%.
• Out-of-Pocket Maximum: The maximum amount you pay each year for medical costs.After reaching the outof-pocket maximum, the plan pays 100% of allowable charges for covered services. TRS-ActiveCare
Per Covered Person
Maximum Per Family*
Zurich Specialty Health Supplemental GAP Medical
$1,000 per Injury or Sickness per Plan Year
4 outpatient occurrences per Family per Plan Year
*This maximum applies to the entire family unit, regardless of the number of covered persons within the family unit. An “occurrence” is the treatment, or series of treatments, for a specific sickness or injury. All expenses related to the treatment of the same or related sickness or injury will accrue toward the out-patient maximum for one occurrence, regardless of whether such treatment is received in more than one calendar year period. If, however, a Covered Person is treatment-free, at any time, for at least 30 consecutive days, they may qualify for an additional outpatient maximum benefit if the family maximum per calendar year has not been met.
Monthly Rates*
Employees and dependents enrolled in the company sponsored Major Medical Plan may enroll for coverage in the Zurich Supplemental GAP Medical Plan.
Serving customers for almost 150 years
Zurich Insurance Group
Founded in Switzerland in 1872, we are one of the world’s most experienced global insurers
• Eligibility
Doing business in the U.S. since 1912
Approximately 55,000 experienced professionals worldwide
Approximately 9,000 employees in North America
Providing a wide range of property and casualty, and life insurance products and services in more than 215 countries and territories
North America contributed approximately $1.43 billion toward Zurich’s $4.2 billion in operating profit in 2020
Insurance a broad range of Middle Market customers as well as more than 95 percent of the Fortune 500
Providing multinational solutions in the U.S. for almost 50 years
Strong investor proposition; resilient business model, clear strategy, and responsible and impactful business
Zurich North America is one of the largest providers of insurance solutions and services to businesses and individuals.
To learn more, visit www.zurichna.com
• Employees enrolled in the company’s sponsored Major Medical Plan are eligible for Gap medical coverage. Employee’s dependents are also eligible for coverage.
• Eligibility waiting period
• Same as Major Medical Plan.
• Inpatient Expense Benefit – Benefits will be paid if a covered person is confined to a hospital as a direct result of an injury sustained in an accident or sickness. Benefits are limited to out-of-pocket expenses incurred by the covered person, including the deductible and coinsurance amounts the covered person is required to pay under the Major Medical Plan.
• Outpatient Expense Benefit – Benefits will be paid for outpatient treatment of an injury sustained in an accident or sickness. Benefits are limited to out-of-pocket expenses incurred by the covered person, including the deductible and coinsurance amounts the covered person is required to pay under the Major Medical Plan.
• Combined Inpatient and Outpatient Expense Benefit –Benefits will be paid if a covered person is confined to a hospital or receives outpatient treatment as a direct result of an injury sustained in an accident or sickness. Benefits are limited to out-of-pocket expenses incurred by the covered person, including the deductible and coinsurance amounts the covered person is required to pay under the Major Medical Plan. All benefits are subject to the Policy Deductible and the Supplemental Medical Coinsurance percentage for the Plan Year shown on the following pages:
• Policy Deductible – Benefits will be payable after the Covered Person has met the “Per Covered Person” Policy Deductible or after the “Per Family” Policy Deductible has been met, whichever occurs first.
• Supplemental Medical Co-insurance – The maximum percentage that will be paid under this Policy for covered expenses incurred by a covered person.
• Plan Year – A consecutive 12-month period during which a covered person’s coverage under the policy is in force.
General exclusions and limitations
This coverage does not cover any loss, treatment, or services resulting from any of the following:
1. Suicide or any attempt at suicide
2. Intentionally self-inflicted Injury or Sickness, while sane or insane
3. Declared or undeclared war, or any act of declared or undeclared war
4. Full-time active duty in the armed forces of any country or international authority
5. Any Injury or Sickness for which the Covered Person is entitled to benefits pursuant to any workers’ compensation law or other similar legislation
6. The Covered Person’s commission of or attempt to commit a felony, assault, sexual assault, riot or insurrection or any Injury resulting from the Covered Person’s provocation of an attack against them
7. Travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Covered Person is
a. Riding as a passenger in any aircraft not intended or licensed for the transportation of passengers
b. Performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft
c. Riding as a passenger in an aircraft owned, leased or operated by the Policyholder or the Covered Person
8. Skydiving, parasailing, parachuting, hang-gliding, bungee-jumping and participation in a contest of speed in power driven vehicles
9. Dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (a) resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or (b) due to congenital disease or anomaly of a covered newborn child
10. Treatment or services for Injury and Sickness provided outside of the United States
11. Rest care or rehabilitative care and treatment (this does not include rehabilitation for treatment of physical disability)
12. Voluntary abortion except, with respect to the Covered Person: (a) where the Insured or the Insured’s Dependent’s life would be endangered if the fetus were carried to term; or (b) where medical complications have arisen from abortion
13. Elective cosmetic surgery (except newborn circumcision)
14. Sterilization and reversal of sterilization
15. Any expense which is not Medically Necessary
16. Prescription drugs
17. Any loss for which the Covered Person is not required to pay a Health Benefit Plan Deductible, co-payment and/or Health Benefit Plan Coinsurance under the Covered Person’s Health Benefit Plan; and
18. Any expense or benefit that is excluded under the Covered Person’s Health Benefit Plan
Health Benefit Plan Limitation
If a Covered Person does not have a Health Benefit Plan on the Covered Person’s Effective Date under this coverage, the Company’s sole obligation will then be to refund all premiums paid for that Covered Person.
GroupNumber: 00067437
CustomerService(888)600-1600
Mondayto FridayI Samto8:30pmET
Workplace benefits
Everyone deserves a Guardian
Everyday, Guardiangives26millionAmericansthe securitytheydeservethroughourinsuranceand wealthmanagementproductsandservices.
We'vepartneredwithyourorganizationtooffer youarangeofemployeebenefits. Insidethispack, you'llfindtheplansyouremployerthinksyoumight benefitfrom.
Know your benefits
Yourbenefitssupportyourphysicaland financialwellbeing, tohelpkeepyouand yourlovedonesprotected.
WithGuardian, you'reingoodhands. We'vebeendeliveringonourpromisesfor over 150years, andwe'relookingforward todoingthesameforyoutoo.
Readthroughthisinformation. Find
Dental insurance
Takingcareof your teeth isabout more thanjust coveringcavitiesand cleanings. It also means accounting for moreexpensive dentalwork, and your overallhealth.
Withdental insurance, routine preventivecarecanleadto betteroverallhealth. Andyou'll beableto save moneyifany extensive dentalworkis required.
Who is it for?
Everyoneshouldhaveaccesstogreatdentalcoverage,whichiswhywe offercomprehensiveplansthatareavailablethroughemployersaspartof yourbenefitofferings.
What does it cover?
Dentalinsurancehelpstoprotectyouroveralloralcare.Thatincludes serviceslikepreventivecleanings,x-rays, restorativeserviceslikefillings, andothermoreseriousformsoforalsurgeryifyoueverneedthem.
Why should I consider it?
Poororalhealthisn'tjustaesthetic,it'salsobeenlinkedtoconditions includingdiabetes,heartdisease,andstrokes.So,whilebrushingand flossingeverydaycanhelpkeepyourteethclean,nothingshouldreplace regularvisitstothedentist.
Youwillreceivethesebenefitsifyoumeettheconditionslistedinthepolicy.
Watch our video
Learnhowdentalinsurancecan protectyourlong-termhealth.
Staying healthy
Joevisitshisdentistforaroutine dentalcleaning,totakecareofhis teethaswellashisoverallhealth.
Oralhealthisaboutmorethanjust teethandgums. It'salsoessential forarangeofotherhealthand wellbeingreasons:
Cardiovasculardisease: Some researchsuggeststhatheart disease, cloggedarteries, and strokesmaybelinkedto inflammationandinfections fromoralbacteria.
Osteoporosis: Weakandbrittle bonesmaybelinkedtotoothloss.
Diabetes: Researchshowsthat peoplewithgumdiseasefindit moredifficulttocontroltheir bloodsugarlevels.
Alzheimer'sdisease: Worsening oralhealthisseenasAlzheimer's diseaseprogresses.
Allinformationcontainedhereis fromthe MayoClinic, Oral Health: AWindowtoYourOverall Health, www.mayoclinic.com.2021.
Your dental coverage
Option I: LOW PLAN plan, you'll have access to one of the largest networks of dentists with two reimbursement levels that give you more control over savings. You will always save money with any dentist in Guardian's network and when they belong to a tier in the Tier I reimbursement level you will maximize your savings. Reimbursement for covered services received from a non-contracted dentist will be based on Guardian's fee schedule.
Option 2: HIGH PLAN plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Out-of-network benefits are based on a percentile of the prevailing fee data for the dentist's zip code.
Dental Plan
8 Guardian®
Your dental coverage
A Sample of Services Covered by Your Plan:
Preventive Care Cleaning (prophylaxis)
Frequency:
Fluoride Treatments
Limits: Oral Exams Sealants (per tooth) X-rays
Basic Care Anesthesia* Fillings+
Repair & Maintenance of Crowns, Bridges & Dentures
Simple Extractions
Surgical Extractions
Major Care Bridges and Dentures
Dental Implants
Inlays, Onlays, Veneers** Perio Surgery
Periodontal Maintenance
Guardian's Preferred Provider Organization consists of Dentists in the DentalGuard Preferred ("DGP") network. These tiers represent specific benefit levels as described in Your Schedule of Benefits. Network access varies by geographic location and zip code. Please visit www.Guardianlife.com to confirm your Dentist's tiered participation.
This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and or Indemnity members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other pathology when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required by your plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. *General Anesthesia - restrictions apply. :j:For PPO and or Indemnity members, Fillings - restrictions may apply to composite fillings.
GUARDIAN® is aregisteredtrademarkofThe
8 Guardian ® Your dental coverage
Manage Your Benefits:
Go to www.Guardianlife.com to access secure information about your Guardian benefits including access to an image of your ID Card. Your on-line account will be set up within 30 days after your plan effective date.
EXCLUSIONS AND LIMITATIONS
■ Important Information about Guardian's DentalGuard Indemnity and Denta!Guard Preferred Network PPO plans: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under preventiveservices), orthodontia (unless expressly provided for), cosmetic or experimental treatments (unless they are expressly provided for), any treatments to the extent benefits are payable by any other payer or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The plan limits benefits for diagnostic
Find A Dentist:
Visit www.Guardianlife.com
Click on "Find A Provider"; You will need to know your plan, which can be found on the first page of your dental benefit summary.
consultations and for preventive, restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract# DG7-P et al.
■ PPO and or Indemnity Special Limitation: Teeth lost or missing before a covered personbecomes insured by this plan. A covered personmay have one or morecongenitally missing teeth or havelostoneormoreteethbefore he became insured by this plan. We won't pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered personbecameinsured by this plan. R3-DG7
DentalGuard Insurance is underwritten and issuedby The Guardian Life Insurance Company ofAmerica, NewYork, NY. Productsare not available in all states. Policylimitationsand exclusionsapply. Optional ridersand/or features may incur additional costs. Plan documents are the finalarbiterof coverage. This policyprovidesDENTAL insurance only.
Policy Form# GP-1-DG2000, et al, GP·l·DEN-16
GUARDIAN® is
Managed Dental Care- Dental DHMO
RATES
SERVICES & PATIENT CHARGES
Managed Dental Care
SERVICES & PATIENT CHARGES (continued)
$1,895
$2,195
$1,050
Managed Dental Care
Comprehensive ortho for dep child to age 18
Comprehensive ortho for other members
Surgical Placement of an Implant, limited to 2 per 12 months, per arch, after 12 months of coverage
PLAN HIGHLIGHTS
The Managed Dental Care plan combines broad dental coverage with a number of cost-saving features. No annual maximums
• No deductibles
• No claim forms
• Specialty services available by referral only
• Full disclosure of out-of-pocket costs
• No exclusions for pre-existing conditions
• No participation requirements
• No employer contribution required
• International Dental Travel Assistance
• International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. AXA Assistance is not affiliated with (The) Guardian Life Insurance (Company of America) ("Guardian"), and the services they provide are separate and apart from the benefits provided by Guardian.
While traveling internationally, Guardian members can get a referral to a local dentist for immediate dental care through the International Dental Travel Assistance Program. This service is available 24/7, in over 200 countries. Coverage will be considered under the out-of-network benefits.
• Managed Dental Care (N500I) Member Office Visit Patient Charge / Copayment Elimination Feature
•
Once a member has had a Managed Dental Care plan for 3 complete years, Guardian will pay the office visit co-pays. This will happen automatically beginning with the policy anniversary.
IMPORTANT NOTES
Rates and premiums are based on the employee data submitted. Final rates and premiums are based on the plan and employee/dependent data provided on the enrollment forms. State specific requirements apply. Two eligible employees must enroll or quote is not valid.
•
• If your plan includes Section 125/Flex Plan, open enrollment must be held the month prior to the renewal/anniversary date.
SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS
• The list of dental services shown is not exhaustive.
In order to be eligible for coverage: Employees must be legally working (a) in the United States or (b) outside the United States, for a US based employer, in a country or region approved by Guardian.
• Managed Dental Care Plans
• This plan provides managed care dental benefits through a network of participating general dentists and specialty care dentists.
Except for limited emergency services, benefits will be provided for services provided by the primary care dentist selected by the member. The member must pay the primary care dentist a patient charge/copayment for most covered services. No benefits will be paid for treatment by a specialist unless the patient is referred by his or her primary care dentist and the referral is approved by the plan.
• Only those services listed in the plan's schedule of benefits are covered.
• Certain services are subject to frequency or other periodic limitations.
• Where orthodontic benefits are specifically included, the plan provides for one course of comprehensive treatment per member.
• Unless specifically included, the Managed Dental Care plan does not provide orthodontic benefits if comprehensive orthodontic treatment or retention is in progress as of the member’s effective date under the Managed Dental Care plan.
• The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The applicable Managed Dental Care documents are the final arbiter of coverage.
•
• GP-1-DHMO-16-TX, et al.
Oral Health Rewards Program
Regular visits to the dentist can help prevent and detect the early signs of serious diseases.
That'swhy Guardian's MaximumRollover Oral HealthRewards Programencouragesandrewardsmembers who visit the dentist, by rollingover part of yourunusedannualmaximum intoa MaximumRolloverAccount (MRA). Thiscanbeused in future years if your plan's annual maximum isreached.
How maximumrollover works*
Dependingonaplan'sannualmaximum, ifclaimsmadefora certain year don't reachaspecifiedthreshold, then theset maximumrolloveramount canberolledover.
Automatic rollover
Submita claim (without exceedingthe paid claims thresholdofabenefit year), and Guardianwillrollover a portionofyour unused annual dentalmaximum.
Maximum rollover account limit
$1,000
Maximumclaims Claims amount that Additionaldollarsadded to The limit that cannot reimburesment determinesrollover eligibility a plan'sannualmaximum be exceededwithinthe for futureyears maximumrolloveraccount
* This examplehas been created forillustrativepurposesonly.
** Ifa plan hasa different annualmaximum forPPO benefits vs. non-PPObenefits, ($1500PPO/$1000 non-PPOfor example) thenon-PPO maximum determinesthe MaximumRollover plan. Maynot beavailablein allstates. Guardian'sDental Insuranceis underwritten andissuedby The Guardian Life Insurance Company ofAmerica, New York, NY.Products arenot availablein all states.Policylimitationsandexclusionsapply. Optional ridersand/or features may incur additionalcosts. Plan documents arethe finalarbiter ofcoverage. Information providedin thiscommunication isfor informationalpurposesonly.DentalPolicy Form No. GP-l-DEN-16. GUARDIAN® is aregisteredservicemark ofThe Guardian Life Insurance Company ofAmerica ® ©Copyright2023 The Guardian Life Insurance CompanyofAmerica. GUARDIAN® isaregistered trademark ofThe Guardian LifeInsuranceCompany ofAmerica
8 Guardian® Guardian Choice
With dental insurance from Guardian, you have the flexibility to choose a plan that works for you, and helps you save.
Bothofthedentalplans availablearedesignedto keep youhealthy, withidenticalpremiums. Thedifferences betweenthem are summarized below, and youcan changeplans each year at yourannualenrollmenttime.
Pickthe plan that bestsuits yourneeds
Choosefrom:
It's easyto save
Findaparticipating doctornear youbyvisiting guardiananytime.com/ fpapp/FPWeb/searchorby downloadingthe Guardian Anytimemobileapp.
Value Plan
NetworkAccess Plan
Description In-networkandout-of-networkbenefitsarepaidatthesamecoinsurancepercentages. Bothplansallow youtoretainthefreedomofchoicetoseeanydentist, in-networkorout ofnetwork.
Coinsurance
Preventiveservicescoveredat 100%.
Coinsuranceforotherservicesishigherthan the NetworkAccess Plan (increasedcoverage).
Preventive services coveredat 100%.
Coinsurancefor other servicesislower thantheValue Plan {decreasedcoverage).
In-network Memberbenefitsarebasedondiscounted{negotiated)rates.
Out-ofnetwork Memberpaysthedifferenceovernetwork negotiatedrates. Membercostsarebasedonusualand customary (UCR)rates.
8 Guardian®
Ourcommitmenttoyou
Pleaseread thedocumentationreferencedbelowcarefully. Thenoticesare intended toprovideyou important informationaboutourinsuranceofferingsandtoprotectyour interests. Certainonesare requiredbylaw.
Important information
Notice Informing Individuals about Nondiscrimination and Accessibility Requirements
GuardiannoticestatingthatitcomplieswithapplicableFederalcivilrightslawsanddoesnotdiscriminatebasedonrace, color,nationalorigin, age,disability,sex,oractualorperceivedgenderidentity.Thenoticeprovidescontactinformationfor filinganondiscriminationgrievance. Italsoprovidescontactinformationforaccesstofreeaidsandservicesbydisabled peopletoassistincommunicationswithGuardian. Visit https://www.guardiananytime.com/notice48 toreadmore.
No Cost Language Services
GuardianprovideslanguageassistanceinmultiplelanguagesformemberswhohavelimitedEnglishproficiency. Visit https://www.guardiananytime.com/notice46 toreadmore.
Dental insurance
Guardian's HIPAA NoticeofPrivacy Practices
Thenoticedescribeshowhealthinformationaboutyoumaybeusedanddisclosedandhowyoucanaccessthisinformation. Visit https://www.guardiananytime.com/notice50 toreadmore.
SanMarcosConsolidatedISD
Welcome to Davis Vision!
care for your vision and eye health - a key part of overall health and wellness! If you are not currently enrolled, please visit our member site at davisvision.com or call 1.877.923.2847 and enter client code 8100 to locate providers or for additional information.
Make an appointment.
Tell your provider you are a Davis Vision member with coverage through San Marcos Consolidated ISD. Provide your member ID number, name and date of birth, and do the same for your covered dependents seeking vision services. Your provider will take care of the rest!
in full. Includes dilation when professionally indicated.
Clear plastic lenses in any single vision, bifocal, trifocal or lenticular prescription. Covered in full. (See below for additional lens options and coatings.)
Covered in Full Frames:
Allowance:
Allowance: Any Fashion or Designer level frame from Davis Vision’s Collection/2 (retail value, up to $160).
$125 toward any frame from provider plus 20% off any balance./1 No copay required.
$175 allowance plus 20% off any balance toward any frame from a Visionworks family of store locations./4 No copay required.
Davis Vision Collection Contacts: Specialty Contacts/3: Covered in full. 15% discount/1 15% discount/1
Covered in Full Contacts: Planned Replacement Disposable Contact Lens Allowance: : From Davis Vision’s Collection/2, up to: Four boxes/multi-packs* Eight boxes/multi-packs*
$150 allowance toward any contacts from provider’s supply plus 15% off balance./1 No copay required.
Covered in full with prior approval.
*Number of contact lens boxes may vary based on manufacturer’s packaging.
SanMarcosConsolidatedISD
Welcome to Davis Vision!
care for your vision and eye health - a key part of overall health and wellness! If you are not currently enrolled, please visit our member site at davisvision.com or call 1.877.923.2847 and enter client code 8101 to locate providers or for additional information.
Make an appointment.
Tell your provider you are a Davis Vision member with coverage through San Marcos Consolidated ISD. Provide your member ID number, name and date of birth, and do the same for your covered dependents seeking vision services. Your provider will take care of the rest!
in full. Includes dilation when professionally indicated.
Clear plastic lenses in any single vision, bifocal, trifocal or lenticular prescription. Covered in full. (See below for additional lens options and coatings.)
Covered in Full Frames: Frame Allowance: VisionworksFrame Allowance: Any Fashion, Designer or Premier level frame from Davis Vision’s Collection/2 (retail value, up to $195).
$150 toward any frame from provider plus 20% off any balance./1 No copay required.
$200 allowance plus 20% off any balance toward any frame from a Visionworks family of store locations./4 No copay required.
Davis Vision Collection Contacts: Specialty Contacts/3: Covered in full. 15% discount/1 15% discount/1
Covered in Full Contacts: Planned Replacement Disposable Contact Lens Allowance: : From Davis Vision’s Collection/2, up to: Four boxes/multi-packs* Eight boxes/multi-packs*
$200 allowance toward any contacts from provider’s supply plus 15% off balance./1 No copay required.
Covered in full with prior approval.
*Number of contact lens boxes may vary based on manufacturer’s packaging.
Frequently Asked Questions
How can I contact Member Services?
Call 1.800.999.5431 for automated help 24/7. Live help is also available seven days a week: Monday-Friday, 8 a.m.-11 p.m. | Saturday, 9 a.m.-4 p.m. | Sunday, 12 p.m.-4 p.m. (Eastern Time). (TTY services: 1.800.523.2847.)
Our Collection offers a great selection of fashionable and designer frames, most of which are covered in full. No wonder 8 out of 10 members select a Collection frame. Log on to our member Web site at davisvision.com and take a look!
When will I receive my eyewear?
Your eyewear will be delivered to your network provider generally lens coatings, provider frames or out-of-stock frames may delay the standard turnaround time.
Claim forms are only required if you visit an out-of-network provider. Claim forms are available on our member Web site.
eyeglasses or contact lenses on different dates or through different provider locations. Complete eyeglasses must be obtained at one time, from one provider. You may not split between a network recommend that all services be obtained from a network provider.
Yes; however, you receive the greatest value by staying in-network. If you go out-of-network, pay the provider at the time of service, then submit a claim to Davis Vision for reimbursement, up to the following amounts: eye exam - $35 | single vision lenses - $25 | bifocal - $40 | trifocal - $45 | lenticular - $80 | frame - $55 | elective contacts - $65 | visually required contacts - $150.
Your vision plan does not cover medical treatment of eye disease or injury; vision therapy; special lens designs or coatings, other than those described herein; replacement of lost eyewear; nonprescription (plano) lenses; contact lenses and eyeglasses in the two pair of eyeglasses in lieu of bifocals.
DAVIS VISION EXTRAS!
One Year Breakage Warranty Repair or replacement of your plan covered spectacle lenses, Collection frame or frame from a network retail location where the Collection is not displayed.
Access a higher frame allowance by visiting a Visionworks family of store locations/6
Additional Savings At most participating network locations, members receive up to 20% off additional eyeglasses, sunglasses contact lenses./7
Mail Order Contact Lenses Replacement contacts (after service ensures easy, convenient, purchasing online and quick, direct shipping to your door. Log on to our member Web site for details.
Laser Vision Correction Up to 25% discount off participating provider’s U&C or 5% off advertised special (whichever is lower). Log on to our member Web site for details and to locate a provider. A One-time/lifetime allowance of $200 is available.
Low Vision Services Comprehensive low vision evaluation
Eye Health & Wellness Log on and learn more about your eyes, health and wellness; common eye conditions that can impair vision; and what you can do to ensure healthy eyes and a healthier life.
For more details… and responsibilities, or more information about Davis Vision, please log on to our member Web site or contact us at 1.800.999.5431.
Davis Vision has made every effort to correctly summarize your vision plan features contract with Davis Vision, the terms of the contract will prevail.
The Standard - Voluntary Long Term Disability (LTD) Insurance
Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select through San Marcos CISD. Written in non-technical language, this is not intended as a complete description of the coverage. If you have additional questions, please check with your human resources representative.
Employer Plan Effective Date
A minimum number of eligible employees must apply and qualify for the proposed plan before Voluntary LTD coverage can become effective. This level of participation has been agreed upon by San Marcos CISD and The Standard.
Eligibility
To become insured, you must be:
A regular employee of San Marcos CISD, excluding temporary or seasonal employees, full-time members of the armed forces, leased employees or independent contractors
Actively at work at least 15 hours each week
A citizen or resident of the United States or Canada
Employee Coverage Effective Date
Please contact your human resources representative for more information regarding the following requirements that must be satisfied for your insurance to become effective. You must satisfy:
Eligibility requirements
An eligibility waiting period (check with your human resources representative)
An evidence of insurability requirement, if applicable
An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.
Benefit Amount
You may select a monthly benefit amount in $100 increments from $300 to $8,000; based on the tables and guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not exceed 66 2/3 percent of your monthly earnings.
Benefits are payable for non-occupational disabilities only. Occupational disabilities are not covered.
Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings
Plan Minimum Monthly Benefit: 10 percent of your LTD benefit before reduction by deductible income
Benefit Waiting Period and Maximum Benefit Period
The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. Benefits are not payable during the benefit waiting period. The maximum benefit period is the period for which benefits are payable. The benefit waiting period and maximum benefit period associated with your plan options are shown below:
Options 1-6: Maximum Benefit Period of To SSNRA for Sickness and Accident
If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65 or to the Social Security Normal Retirement Age (SSNRA) or 3 years 6 months, whichever is longer. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins:
Age Maximum Benefit Period
62 To SSNRA, or 3 years 6 months, whichever is longer
63 To SSNRA, or 3 years, whichever is longer
64 To SSNRA, or 2 years 6 months, whichever is longer
652 years
66 1 year 9 months
67 1 year 6 months
68 1 year 3 months
69+ 1 year
FIRST DAY HOSPITALIZATION BENEFIT
With this benefit, if an insured employee is hospital confined for at least four hours, is admitted as an inpatient and is charged room and board during the benefit waiting period, the benefit waiting period will be satisfied. Benefits become payable on the date of hospitalization; the maximum benefit period also begins on that date. THIS FEATURE IS INCLUDED ONLY ON LTD PLANS WITH BENEFIT WAITING PERIODS OF 30 DAYS OR LESS.
Preexisting Condition Exclusion
A detailed description of the preexisting condition exclusion is included in the Group Policy. If you have questions, please check with your human resources representative.
Preexisting Condition Period: The 90-day period just before your insurance becomes effective Exclusion Period: 12 months
Preexisting Condition Waiver
The Standard may pay benefits for up to 90 days even if you have a preexisting condition. After 90 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply.
Own Occupation Period
For the plan’s definition of disability, as described in your brochure, the own occupation period is the first 24 months for which LTD benefits are paid.
Any Occupation Period
The any occupation period begins at the end of the own occupation period and continues until the end of the maximum benefit period.
Other LTD Features
Employee Assistance Program (EAP) – This program offers support, guidance and resources that can help an employee resolve personal issues and meet life’s challenges.
Family Care Expense Adjustment – Disabled employees faced with the added expense of family care when returning to work may receive combined income from LTD benefits and work earnings in excess of 100 percent of indexed predisability earnings during the first 12 months immediately after a disabled employee’s return to work.
Special Dismemberment Provision – If an employee suffers a lost as a result of an accident, the employee will be considered disabled for the applicable Minimum Benefit Period and can extend beyond the end of the Maximum Benefit Period
Reasonable Accommodation Expense Benefit – Subject to The Standard’s prior approval, this benefit allows us to pay up to $25,000 of an employer’s expenses toward work-site modifications that result in a disabled employee’s return to work.
Survivor Benefit – A Survivor Benefit may also be payable. This benefit can help to address a family’s financial need in the event of the employee’s death.
Return to Work (RTW) Incentive – The Standard’s RTW Incentive is one of the most comprehensive in the employee benefits history. For the first 12 months after returning to work, the employee’s LTD benefit will not be reduced by work earnings until work earnings plus the LTD benefit exceed 100 percent of predisability earnings. After that period, only 50 percent of work earnings are deducted.
Rehabilitation Plan Provision – Subject to The Standard’s prior approval, rehabilitation incentives may include training and education expense, family (child and elder) care expenses, and job-related and job search expenses.
When Benefits End
LTD benefits end automatically on the earliest of:
The date you are no longer disabled
The date your maximum benefit period ends
The date you die
The date benefits become payable under any other LTD plan under which you become insured through employment during a period of temporary recovery
The date you fail to provide proof of continued disability and entitlement to benefits
Rates
Employees can select a monthly LTD benefit ranging from a minimum of $300 to a maximum amount based on how much they earn. Referencing the appropriate attached charts, follow these steps to find the monthly cost for your desired level of monthly LTD benefit and benefit waiting period:
1.Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum amount you can receive. If your earnings fall between two amounts, you must select the lower amount.
2.Select the desired monthly LTD benefit between the minimum of $300 and the determined maximum amount, making sure not to exceed the maximum for your earnings.
3.In the same row, select the desired benefit waiting period to see the monthly cost for that selection.
If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the premium payment of your desired benefit, please contact your human resources representative.
Group Insurance Certificate
If you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage. The information presented above is controlled by the group policy and does not modify it in any way. The
1-6 (Continued)
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DURING THE LAST SIX MONTHS, HAS THE PROPOSED INSURED:
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FlexiblePremiumAdjustableLifeInsurancetoage121.PolicyFormICC18PRFNG-NI-18orFormSeriesPRFNG-NI-18.Somelimitationsapply.Seethe PureLife-plusbrochurefordetails.TexasLifeislicensedtodobusinessinthe DistrictofColumbiaandeverystatebutNewYork. 19M016-C1092(exp0321) You own it
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Group Rates for You
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Group Rates for Your Spouse / Domestic Partner
Note: Rates are subject to change and can vary over time. Dependent Children Monthly Premium for Life Insurance Coverage
Group Rates for Your Dependent Children
BASE POLICY BENEFITS
BENEFIT PROVISIONS. We will pay the benefits described in the Certificate for the treatment of an Insured Person’s Cancer, provided he or she is covered under an issued Certificate which remains in force. Payment will be made in accordance with all applicable policy provisions. Benefits are payable for a positive diagnosis that begins after the Effective Date. The positive diagnosis must be for Cancer as defined in the policy.
1.POSITIVE DIAGNOSIS BENEFIT. We will pay the Actual Charge but not to exceed $300 per Calendar Year for one test that confirms the Positive Diagnosis of Cancer in an Insured Person. This benefit is not payable for multiple diagnoses of the same Cancer or for Cancer that metastasizes or for recurrence of the same Cancer.
2.NATIONAL CANCER INSTITUTE DESIGNATED COMPREHENSIVE CANCER TREATMENT CENTER EVALUATION/CONSULTATION BENEFIT We will pay the Actual Charge, but not to exceed a lifetime maximum of $750 , if an Insured Person is diagnosed with Internal Cancer and seeks evalu ation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Insured Person’s place of residence, We will also pay the transportation and lodging expenses incurred but not to exceed a lifetime maximum of $350 . This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation and Lodging Expense Benefits of the Policy. This benefit is payable one time during the lifetime of the Insured Person.
3.SECOND AND THIRD SURGICAL OPINION EXPENSE BENEFIT We will pay the Actual Charge for a written second surgical opinion concerning the recommendation of Cancer surgery and if the second surgical opinion is in conflict with that of the Physician originally recommending the surgery and the Insured Person desires a third opinion, We will the Actual Charge for a written third surgical opinion. The Physician providing the second or third surgical opinion cannot be associated with the Physician who orig inally recommended the surgery. This benefit is not payable the same day the National Cancer Institute Evaluation/Consulting Benefit is payable.
4.MEDICAL IMAGING, TREATMENT PLANNING AND MONITORING EXPENSE BENEFIT We will pay the Actual Charge, but not to exceed $1,000 per Calendar Year, for laboratory tests, diagnostic X-rays, medical images, when used in Cancer treatment plannings related to Radiation Treatment, Chemotherapy or Immunotherapy.
5. ANTI-NAUSEA MEDICATION EXPENSE BENEFIT We will pay the Actual Charge for anti-nausea medication, but not to exceed $150 per calendar month , when an Insured Person is prescribed such medication as the result of Radiation Treatmen t, Chemotherapy or Immunotherapy treatments for Cancer.
6. COLONY STIMULATING FACTOR OR IMMUNOGLOBULIN EXPENSE BENEFIT We will pay the Actual Charge but not to exceed $1,000 per Calendar Month for Colony Stimulating Factor Drugs or Immunoglobulins presc ribed by a Physician or Oncologist during an Insured Person’s Cancer treatment regimen for which benefits are payable unde r the Radiation, Chemotherapy and Immunotherapy Benefit of this Policy or rider attached to it.
7.OUTPATIENT HOSPITAL OR AMBULATORY SURGICAL CENTER EXPENSE BENEFIT We will pay the Actual Charge from an Ambulatory Surgical Center or Outpatient department of a Hospital for the use of its facilities for the performance of a surgical procedure covered under this Policy but not to exceed $350 per day.
8.PROSTHESIS EXPENSE BENEFIT
(A.) Surgically Implanted Breast Prosthesis We will pay the Actual Charge for a surgically implanted prosthetic device required and prescribed to restore normal body contour lost as the direct result of an Insured Person’s breast removal for the treatment of Cancer. The Surgically Implanted Breast Prosthesis Benefit does not include coverage for breast reconstruction surgery which may be covered under the Surgical Schedule within the Surgical and Anesthesia Benefits Rider.
(B.) Non-Surgically Implanted Prosthesis We will pay the Actual Charge incurred not to exceed $2,000 per amputation for an artificial limb
or other non-surgically implanted prosthetic device that is prescribed and required to restore normal body function lost as the direct result of an Insured Person’s amputation for the treatment of Cancer . We will pay a lifetime maximum of $2,000 per amputation The cost of replacement of a prosthetic device is not covered. Hairpieces or wigs are not covered under this benefit.
9.NON-LOCAL TRANSPORTATION EXPENSE BENEFIT We will pay the Actual Charge, but not to exceed the coach fare on a Common Carrier for the Insured Person and one adult companion’s travel to a Hospital, Radiation Therapy Treatment Cen ter, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center where the Insured Person receives tr eatment for Cancer. This benefit is payable only if the treatment is not available Locally but is available Non-Locally. The adult companion may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. At the option of the Insured Person, We will pay a single private vehicle mileage allowance of $.50 per mile for Non-Local transportation in lieu of the common carrier coach fare.
10.LODGING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $75 per day for a room in a motel, hotel or other appropriate lodging facility (other than a private residence), when an Insured Person receives treatment for Cancer at a Non-Local Hospital, Radiation Therapy Treatment Center, Chemother apy Treatment Center, Oncology Clinic or any other specialized treatment center. The room must be occupied by the Insured Person or an a dult companion which may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. This benefit is limited to 100 days per Calendar Year
11.INPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT We will pay the Actual Charge not to exceed $300 per day for the procurement cost, administration, processing and cross matching of b lood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Inpatient.
12.OUTPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT We will pay the Actual Charge not to exceed $300 per day for the procurement cost, administration, processing and cross matching of blood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Outpatient.
13.BONE MARROW DONOR EXPENSE BENEFIT We will pay the Daily Hospital Confinement Benefit shown on the Certificate Schedule for each day a live donor, other than the Insured Person, is confined in a Hospital for the harvesting of bone marrow or stem cells used in a bone marrow or stem cell tr ansplant for the treatment of an Insured Person’s Cancer.
14.BONE MARROW OR STEM CELL TRANSPLANT EXPENSE BENEFIT We will pay the Actual Charge not to exceed a lifetime maximum of $15,000 for surgical and anesthesia procedures (including the harvesting and subsequent re-infusion of blood cells or peripheral stem cells) performed for a bone marrow transplant and/or a peripheral stem cell transplant for the treatment of an Insured Person’s Cancer. This benefit will be paid in lieu of the Surgical Expense Benefit and the Anesthesia Expense Benefit which may be described in a rider attached to an issued Certificate.
15.AMBULANCE EXPENSE BENEFIT We will pay the Actual Charge for ambulance service if an Insured Persons is transported to a Hospital where he or she is admitted as an inpatient for the treatment of Cancer . The ambulance service must be provided by a licensed professional ambulance company or an ambulance owned by the Hospital.
16.INPATIENT OXYGEN EXPENSE BENEFIT We will pay the Actual Charge not to exceed $300 per Hospital confinement for oxygen prescribed by a Physician and received by an Insured Person while confined in a Hospital for the treatment of Cancer
17.ATTENDING PHYSICIAN EXPENSE BENEFIT We will pay the Actual Charge not to exceed $40 per day for the professional services of a Physician or Oncologist rendered to an Insured Person while he or she is confined in a Hospital fo r the treatment of Cancer. This benefit is payable only if the Physician or Oncologist personally visits the Hospital room occupied by the Insured Person and the amount stated is the maximum amount that will be payable for each day of Hospital confinement regardless of the number of visits made by one or more Physicians or Oncologists.
18.INPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $150 per day for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined in a Hosp ital for the treatment of Cancer. The Nurse must provide services other than those normally provided by the Hospital and the Nurse may not be an employee of the Hospital or an Immediate Family Member of the Insured Person.
19.OUTPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $150 per day limited to the same number of days of the prior Hospital confinement for the full time service of a Nurse that is required an d ordered by a Physician when an Insured Person is confined indoors at home as the result of Cancer . This benefit is not payable if the services of the Nurse are custodial in nature or to assist the Insured Person in the activities of daily living. This benefit is not paya ble when the Nurse is a member of the Insured Person’s Immediate Family. Charges mus t begin following a period of Hospital confinement for which benefits are payable under this Certificate.
20.CONVALESCENT CARE FACILITY EXPENSE BENEFIT We will pay the Actual Charge not to exceed $100 per day for an Insured Person’s confinement in a Convalescent Care Facilit y. The maximum number of days for which this benefit is payable will be the number of days in the last Period of Hospital Confinement that immediately preceded admission to a Convalescent Care Facility. The Convalescent Care Facility Confinement must: be due to Cancer ; begin within 14 days after the Insured Person has been discharged from a Hospital for the treatment of Cancer ; be authorized by a Physician as being medically necessary for the treatment of Cancer.
21.RENTAL OR PURCHASE OF MEDICAL EQUIPMENT EXPENSE BENEFIT We will pay the lesser of the Actual Charge not to exceed $1,500 per Calendar Year for either the rental or purchase of covered medical equipment designed for home use, required and ordered by the Insured Person’s attending Physician as the direct result of the treatment of Cancer. Covered medical equipment includes wheel chair, oxygen equipment, respirator, braces, crutches or hospital bed .
22.HOME HEALTH CARE EXPENSE BENEFIT We will pay benefits for the following Covered Charges when a Insured Person requires Home Health Care for the treatment of Cancer.
1. Home Health Care Visits - We will pay the Actual Charge for Home Health Care Visits not to exceed $75 for each day on which one or more such visits occur. We will not pay this benefit for more than 60 days in any Calendar Year.
2. Medicine and Supplies - We will pay the Actual Charge not to exceed $450 in any Calendar Yea r for drugs, medicine, and medical supplies provided by or on behalf of a Home Health Care Agency.
3. Services of a Nutritionist - We will pay the Actual Charge not to exceed a lifetime maximum of $300 for the services of a nutritionist to set up programs for special dietary needs.
23.HOSPICE CARE EXPENSE BENEFIT We will pay the Actual Charge for Hospice Care not to exceed $100 per day , when such care is required because of Cancer . This benefit is payable whether confinement is required in a Hospice Center or services are provided in the Insured Person’s home by a Hospice Team. Eligibility for payments will be based on the following conditions being met:(1) the Insured Person has been given a prognosis as being Terminally Ill with an estimated life expectancy of 6 months or less; and (2) We h ave received a written summary of such prognosis from the attending Physician. We will not pay this benefit while the Insured Person is confined to a Hospital or Convalescent Care Facility. The lifetime maximum benefit is 365 days of Hospice Care
24.HAIRPIECE EXPENSE BENEFIT We will pay the Actual Charge not to exceed a lifetime maximum of $150 for the purchase of a wig or hairpiece that is required as the direct result of hair loss due to Cancer treatment
25.PHYSICAL, SPEECH, AUDIO THERAPY AND PSYCHOTHERAPY EXPENSE BENEFIT
We will pay the Actual Charge not to exceed $25 per therapy session for:
1.Physical therapy treatments given by a license Physical Therapist, or
2.Speech therapy given by a licensed Speech Pathologist/Therapist; or
3.Audio therapy given by a licensed Audiologist; or
4.Psychotherapy given by a licensed Psychologist. These sessions may be given at an institute of physical medicine and rehabilitation, a Hospital, or the Insured Person’s home. These treatments must be given on an Outpatien t basis unless the primary purpose of a Hospital confinement is for treatment of Cancer other than with physical, speech or audio therapy or psychotherapy. Benefits may not exceed $1,000 per Calendar Year.
26.WAIVER OF PREMIUM. We will waive the premiums starting on the first premium due date following a 60 day period of Total Disability of the Named Insured due to Cancer. The Named Insured must: (a) be receiving treatment for such Cancer for which benefits ar e payable under this Certificate; and (b) remain disabled for 60 consecutive days. We will waive premiums for as long as the Named Insured remains Totally Disabled.
THIS IS A CANCER ONLY POLICY, which should be used to supplement your existing health care protection.
RENEWABILITY. Coverage will terminate when the Group Master Policy terminates or when required premium remains unpaid after expiration of the Grace Period.
PREMIUM RATES. We may change the premium rates for coverage only if we also change the rates for all other Certificates issued under the Group Master Policy.
EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s coverage regardless of the Date of Positive Diagnosis.
PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing Conditions during the 12 months after coverage becomes effective for such Insured Person.
“Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the effective date of coverage for each Insured Person.
Insurance coverage is provided by form number series LG- 6040 and associated riders. This advertisement highlights some features of the Certificate and riders, but is not the insurance contract. An is sued Master Group Policy, Certificate and riders set forth, i n detail, the rights and obligations of both the insured and the insu rance company. Please read the policy, certificate and riders for detailed coverage information.
ADDITIONAL BENEFITS AMOUNTS
ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041)
Benefit
FIRST OCCURRENCE BENEFIT RIDER (form LG-6043)
ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT
BENEFIT RIDER (form LG-6045)
SURGICAL BENEFIT RIDER (form LG-6048)
DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less Confinements of 31 Days or More
Specified Disease Benefit
SPECIFIED DISEASE BENEFIT RIDER (form LG-6052)
COVERS THESE 38 SPECIFIED DISEASES
Addison’s Disease
Amyotrophic Lateral Sclerosis
Botulism
Bovine Spongiform Encephalopathy
Budd-Chiari Syndrome
Cystic Fibrosis
Diptheria
Encephalitis
Epilepsy
Hansen’s Disease
Histoplasmosis
Legionnaire’s Disease
Lyme Disease
Lupus ErythematosusRocky Mountain Spotted Fever
Malaria
Meningitis
Sickle Cell Anemia
Tay-Sachs Disease
Multiple Sclerosis Tetanus
Muscular Dystrophy
Toxic Epidermal Necrolysis
Myasthenia Gravis Tuberculosis
Neimann-Pick DiseaseTularemia
Osteomyelitis
Poliomyelitis
Q Fever
Rabies
Reye’s Syndrome
Rheumatic Fever
BENEFITS
Typhoid Fever
Undulant Fever
West Nile Virus
Whipple’s Disease
Whooping Cough
Oneunit of coverage is included for the premium rates.
METLIFE Critical Illness Insurance Summary
Spouse/Domestic Partner1
Dependent Child(ren)2
or
100%of the employee’s Initial Benefit
Coverage is guaranteed provided you are actively at work.3
Coverage is guaranteed provided the employee is actively at workand the spouse/domestic partner is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3
100%ofthe employee’s Initial Benefit Coverage is guaranteed provided the employee is actively at workand the dependent is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3
BENEFIT PAYMENT
Your Initial Benefit provides a lump-sum payment upon the first diagnosis of a Covered Condition. Your plan pays a Recurrence Benefit4 for the following Covered Conditions: Heart Attack, Stroke, Coronary Artery Bypass Graft, Full Benefit Cancer and Partial Benefit Cancer. A Recurrence Benefitis only available if an Initial Benefit has been paid for the Covered Condition. There is a Benefit Suspension Period between Recurrences.
The maximum amount that you can receive through your Critical Illness Insurance plan is called the Total Benefit and is 3 times the amount of your Initial Benefit. This means that you can receive multiple Initial Benefit and Recurrence Benefit payments until you reach the maximum of 300% or $30,000or $60,000.
Please refer to the table below for the percentage benefit amount for each Covered Condition.
Benefit Cancer5
Benefit Cancer5
Coronary Artery Bypass Graft7
Kidney Failure
Alzheimer’s Disease8
of
100% of Initial Benefit Not applicable
100% of Initial Benefit Not applicable
Major Organ Transplant Benefit 100% of Initial Benefit
22 Listed Conditions
22 Listed Conditions
applicable
of Initial Benefit
MetLife Critical Illness Insurance will pay 25% of the Initial Benefit Amount for each of the 22 Listed Conditions until the Total Benefit Amount is reached. A Covered Person may only receive one payment for each Listed Condition in his/her lifetime. The Listed Conditions are Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease;malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis.
Example of Initial & Recurrence Benefit Payments
The example below illustrates an employee who elected an Initial Benefit of $10,000 and has a Total Benefit of 3 times the Initial Benefit Amount or $30,000.
Heart Attack – first diagnosis
Heart Attack – second diagnosis, two years later
Kidney Failure – first diagnosis, three years later
or 100%
Benefit payment of $5,000 or 50% $15,000
or 100% $5,000
SUPPLEMENTAL BENEFITS
MetLife provides coverage for the Supplemental Benefits listed below. This coverage would be in addition to the Total Benefit Amount payable for the previously mentioned Covered Conditions.
Health Screening Benefit10After your coverage has been in effect for thirty days, MetLife will provide an annual benefit* of $50or $100 per calendar year for taking one of the eligible screening/prevention measures. MetLife will pay only one health screening benefit per covered person per calendar year. For a complete list of eligible screening/prevention measures, please refer to the Disclosure Statement/Outline of Coverage.
INSURANCE 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.
How do I enroll?
QUESTIONS & ANSWERS
Enroll for coverage at USB School Groups-San Marcos Employer website.
Who is eligible to enroll?
Regular active full-time employees who are actively at work along with their spouse/domestic partnerand dependent childrencan enroll for MetLife Critical Illness Insurance coverage.3
How do I pay for coverage?
Coverage is paid through convenient payroll deduction.
What is the coverage effective date?
The coverage effective date is 09/01/2018.
If I Leave the Company, Can I Keep My Coverage? 11
Under certain circumstances, you can take your coverage with you if you leave. You must make a request in writing within a specified period after you leave your employer. You must also continue to pay premiums to keep the coverage in force.
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. Individuals with a TTY may call 1-800-855-2880.
Footnotes:
1 Coverage for Domestic Partners, civil union partners and reciprocal beneficiaries varies by state. Please contact MetLife for more information.
2 Dependent Child coverage varies by state. Please contact MetLife for more information.
3 Coverageis guaranteed provided (1) the employee is actively at work and (2) dependents 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. Additional restrictions apply to dependents serving in the armed forces or living overseas.
4 We will not pay a Recurrence Benefit for a Covered Condition that Recurs during a Benefit Suspension Period. We will not pay a Recurrence Benefit for either a Full Benefit Canceror a Partial Benefit Cancer unless the Covered Person has not had symptoms of or been treated for the Full Benefit Cancer or Partial Benefit Cancer for which we paid an Initial Benefit during the Benefit Suspension Period
5 Please review the Disclosure Statement or Outline of Coverage/Disclosure Documentfor specific information about cancer benefits.Not all types of cancer are covered. Some cancers are covered at less than the Initial Benefit Amount.For NH-sitused cases and NH residents, there is an initial benefit of $100 for All Other Cancers.
6 In certain states, the covered condition is Severe Stroke.
7 In NJ sitused cases, the Covered Condition is Coronary Artery Disease.
8 Please review the Outline of Coveragefor specific information about Alzheimer’s disease.
10 The Health Screening Benefit is not available in all states. See your certificate for any applicable waiting periods.There is a separate mammogram benefit for MT residents and for cases sitused in CA and MT.
11 Eligibility forportability 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.
CRITICAL ILLNESS INSURANCE (CII)IS A LIMITED BENEFIT GROUP INSURANCE POLICY. Like most group accident and health insurance policies, MetLife’s CII policies contain certain exclusions, limitations and terms for keeping them in force. Product features and availability may vary by state. In most plans, there is a preexisting condition exclusion. In most states, after a covered condition occurs there is a benefit suspension period during which most plans do not pay recurrence benefits. Attained Agerates are based on 5-year age bands and will increase when a Covered Person reaches a new age band. A more detailed description of the benefits, limitations, and exclusions can be found in the applicable Disclosure Statement or Outline of Coverage/Disclosure Document available at time of enrollment. For complete details of coverage and availability, please refer to the group policy form GPNP07-CI or GPNP09-CI, orcontact MetLife for more information. Benefits are underwritten by Metropolitan Life Insurance Company, New York, New York.
MetLife's Critical Illness Insurance is not intended to be a substitute for Medical Coverage providing benefits for medical treatment, including hospital, surgical and medical expenses. MetLife's Critical Illness Insurance does not provide reimbursement for such expenses.
San Marcos Consolidated ISD
•American Fund/Capital Guardian
•American United Life Ins Co 1
•Americo Financial Life/Annuity
•Ameriprise Financial/RiverSource
•Athene Annuity and Life (Aviva)
•Consolidated Financial Corp. - GAFRI
•Corebridge Financial (formerly AIG/VALIC)
•Equitable (formerly AXA)
•Fidelity Security Life Ins. Co.
•Fiduciary Trust Intl-Franklin Templeton
•GWN/Employee Deposit Acct
•Horace Mann Life Ins. Co.
•Industrial Alliance - (Sec.Ben.)
•Invesco OppenheimerFunds
•ISC Group Inc
•Jackson National Life III
•Lincoln National
•Midland National Life Insurance
•National Life Group (LSW)
•North American Company 2
•NY Life Ins. & Annuity Corp.
•Orion Portfolio Solutions, LLC (Formerly FTJ FundChoice)
•PenServ SmartSAV (formerly Foresters)
•PlanMember Services Corp.
•RBFCU Retirement Program
•ROTH - Consolidated Financial Corp.-GAFRI
•ROTH - Equitable (formerly AXA)
•ROTH - Industrial Alliance - (Sec.Ben.)
•ROTH - Invesco OppenheimerFunds
•ROTH - ISC Group Inc
•ROTH - National Life Group (LSW)
•ROTH - Orion Portfolio Solutions, LLC (Formerly FTJ FundChoice)
•ROTH - PenServ SmartSAV (formerly Foresters)
•ROTH - RBFCU Retirement Program
•ROTH - Security Benefit
•Security Benefit
•TransAmerica
•Vanguard Fiduciary Trust Co.
•Victory Capital (USAA Mutual Funds)
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.
No matter how comprehensive your local in-network coverage may be, you still
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
EMERGENCY TRANSPORTATION COSTS
MASA MTS is hereto protect its members andtheir families from the shortcomings of health insurance coverageby providingthem with comprehensivefinancial protectionfor lifesaving emergency transportation services, both at home and away fromhome.
Many American employers and employees believe that their health insurance policies cover most, if notall ambulance expenses Thetruth is, they DONOT!
Even after insurance payments for emergency transportation, you couldreceive a bill up to $5,000 for ground ambulanceand as high as $70,000 for air ambulance. The financial burdens for medical transportation costs are veryreal.
HOW MASA IS DIFFERENT
Across the US there are thousands of ground ambulance providers and hundreds of air ambulance carriers. ONLYMASA offers comprehensive coverage since MASA is a PAYERand not aPROVIDER!
ONLY MASA provides over 1.6million members with coverage for BOTH ground ambulance and air ambulance transport, REGARDLESS of which provider transports them.
Members are covered ANYWHEREin all50 states andCanada!
Additionally, MASA provides a repatriation benefit: if a member is hospitalized more than 100 miles from home, MASA can arrangeand pay to have them transported to a hospital closer to their place of residence.
Any Ground. Any Air. Anywhere.™
A MASA Membership prepares you for the unexpectedandgives you the peaceof mind to access vital emergency medical transportation no matter where you live, for a minimal monthlyfee.
• Onelow fee for the entire family
• NO deductibles
• NO health questions
• Easy claims process
For more information, pleasecontact Your Broker or MASA Representative