HUMAN RESOURCES ORIENTATION CHECKLIST EMPLOYEE NAME: Position:
DATE OF HIRE:
REVIEW WITH NEW EMPLOYEE S
S
S
Job Description (on intranet) A - Human Resources Orientation Checklist D - Introductory Period Acknowledgement form F - TCS Employee Handbook Acknowledgement Form H - Confidentiality Agreement Form
Employment Letter B - District Mission and Vision Statement E - Benefit Summary
K - Hepatitis B Vaccine M - Payroll Handbook P - Electronic Funds Transfer **Copy of VOIDED CHECK** S - Payroll Information Sheet T – TCS Amendment to NonSubscription, Employee Injury Plan W - Auto Insurance Coverage Form
C - School Calendar F - TCS Employee Handbook
G - HIPPA Guide & PowerPoint
G - HIPAA Acknowledgement Form
I – Computer Confidentiality Statement K - Hepatitis B Vaccine Acceptance/Declination Form N – Time Correction Form Q - Social Security Statement Form T - Receipt and Arbitration Acknowledgment U - I-9 Form
J - Bloodborne Pathogens Exposure Control Plan with Receipt L - HIV/AIDS in the Workplace
X – New Health Insurance Marketplace
X - New Health Insurance Marketplace Acknowledgement
O - Pay Schedule R - W-4 Form T - Amendment to Employee Occupational Injury Benefit Plan V – Staff Emergency Contact Form
Y - Security Release Form (S – Signature Required)
I HAVE READ AND UNDERSTAND THE PERSONNEL POLICES OF TRINITY CHARTER SCHOOL. I ALSO UNDERSTAND THAT I HAVE 31 DAYS FROM MY DATE OF HIRE TO SUBMIT MY INSURANCE FORMS TO THE HUMAN RESOURCE DEPARTMENT FOR PROCESSING.
Signature (Employee)
Date Orientation Completed
Orientation Presented by – Name Printed
Signature
BENEFIT INFORMATION TO REVIEW WITH NEW EMPLOYEE (if applicable) (all forms listed below must be completed & turned in within 31 days of hire) Z1- TRS-ActiveCare Enrollment Guide Z2 - TRS-ActiveCare Enrollment Application (paper) Z3 - Employee Benefit Guide Z4- Cafeteria Plan (Section 125) Z5 - Special Enrollee Notification Z6 - General Notice of Special Enrollment Rights and Preexisting Condition Exclusion
CENTRAL OFFICE use only Time Reporting System New Hire Reporting – Office of Attny General Mid-Tex Benefits Cooperative
HRB TRS Insurance EIF
7/14
PURPOSE The purpose of Trinity Charter Schools is to empower lifelong learners to transition successfully into the world.
MISSION Mission — a brief, clear, and compelling goal that serves to unify an organization’s efforts. An effective mission must stretch and challenge the organization, yet be achievable. It is tangible, value-driven, energizing, highly focused and moves the organization forward. It is crisp, clear, engaging — it reaches out and grabs people in the gut. People “get it” right away; it requires little or no explanation. A mission has a finish line for its achievement and is proactive. A mission should walk the boundary between the possible and impossible.
Trinity Charter Schools educates and empowers STUDENTS to transform and reclaim their lives.
SHARED VISION Shared visions emerge from personal visions. This is how they derive their energy and how they foster commitment . . . If people don’t have their own vision, all they can do is “sign up” for someone else’s. The result is compliance, never commitment. Senge, The Fifth Discipline
Specific description of what it will be like when the mission is achieved. Provokes emotion and generates excitement. Transforms the mission from words into pictures. Brings the mission to life.
TRINITY CHARTER SCHOOL VISION 2012 Students will be engaged in a transformation process that begins with behavior modification, and utilizes challenging curriculum, includes individualized and engaging instruction, provides ongoing assessment and feedback of student progress, and occurs in a safe, structured and caring environment. When the mission of TCS is implemented … 1. Information will be shared horizontally and vertically across the district to facilitate the exchange of data and best practices. 2. Teachers will be working together to analyze data and collaborate on instruction. 3. Classrooms will be clean and organized to promote a safe, learner-centered environment. 4. Students will show ownership of education and will be active learners who drive their own instruction. 5. When students leave, they will add to and continue successful habits to garner high achievement throughout their lives. In driving the vision of our shared mission the district leadership will provide structure and support for:
Continued cross-campus communication and collaboration.
Opportunities for professional growth.
Repositories and transparent access to district and campus data.
Programs and tools for curriculum and instruction.
Safe, clean and appropriate facilities and environments.
All structures, supports and initiatives will be continually evaluated to best serve the needs of our students and faculty. TCS teachers plan instructional context and learning goals based on Texas State Standards. Students at TCS are engaged in intellectually demanding tasks that require higher order and critical thinking skills. TCS Staff uses multiple sources of data from formative and summative assessments to target instruction and measure program effectiveness. The learning environment at TCS is caring, inviting, and safe. It is achieved as staff members model the way for students, for each other, and for the community.
2014‐2015 School Calendar AUGUST 2014 S M T W T
LEGEND
F
SEPTEMBER 2014 S
S M T W T
1 2 1 3 4 5 6 7 8 9 7 8 10 11 12 13 14 15 16 14 15 17 18 19 20 21 22 23 21 22 24 25 26 27 28 29 30 28 29 31
F
OCTOBER 2014 S
F
18‐22 ‐ Full Day all staff in‐service
1 ‐ Labor Day Holiday
6 ‐ End of 1st Six week grading pd.
(unless it is a specified In‐Service day)
25 ‐ First day of school
15 ‐ Progress Reports
20‐23 TAKS Exit Level Assessments
First/Last day of classes
27 ‐ Progress Reports
NOVEMBER 2014 S M T W T
(7:30 a.m. ‐ 3:30 pm)
1 1 2 2 3 4 5 6 7 8 7 8 9 9 10 11 12 13 14 15 14 15 16 16 17 18 19 20 21 22 21 22 23 23 24 25 26 27 28 29 28 29 30 30
*School in session only if needed
STAAR Assessment T TAKS Assessment
F
DECEMBER 2014
Full Day All Staff In‐service
Bad Weather Make‐Up Day
S
S M T W T 3 10 17 24 31
4 11 18 25
F 5 12 19 26
JANUARY 2015 S
1 ‐ Winter Break Holiday
5 ‐ Make‐up date for STAAR English
2 ‐ Full day all staff in‐service
26‐28 ‐ Thanksgiving Holiday
12 ‐ Progress Reports
16 ‐ End of 3rd Six weeks grading pd.
22‐31 ‐ Winter Break Holiday
19 ‐ MLK Day Holiday 20 ‐ Full day all staff in‐service
FEBRUARY 2015
October 27, 2014
S M T W T
December 12, 2014
1 2 3 8 9 10 15 16 17 22 23 24
Six Week Grading Period Ends
F
MARCH 2015 S
S M T W T
4 5 6 7 1 2 T 3 T 11 12 13 14 8 9 10 18 19 20 21 15 16 17 25 26 27 28 22 23 24 29 3031
4 T 11 18 25
5T 12 19 26
F
APRIL 2015 S
S M T W T
F
6 7 1 2 3 13 14 5 6 7 8 9 10 20 21 12 13 14 15 16 17 27 28 19 20 2122 23 24 26 27 28 29 30
10 ‐ Progress Reports
2‐5 ‐ TAKS Assessment
1 ‐ STAAR Assessment
1st Six Weeks ‐ October 6, 2014
16 ‐ President's Day
5 ‐ End of 4th Six weeks grading pd.
2 ‐ STAAR Assessment Make up
2nd Six Weeks ‐ November 17, 2014
17 ‐ Full Day all staff in‐service
9‐13 ‐ Spring Break Holiday
3 ‐ Good Friday Holiday
30‐31 ‐ STAAR Assessments
21‐22 ‐ STAAR Assessments
3rd Six Weeks ‐ January 16, 2015
MAY 2015
5th Six Weeks ‐ April 24, 2015
Report cards mailed October 13, 2014 November 24, 2014 January 23, 2015 March 19, 2015
S 4 11 18 25
24 ‐ End of 5th Six weeks grading pd.
4th Six Weeks ‐ March 5, 2015
6th Six Weeks ‐ June 8, 2015
S
1‐5 ‐ STAAR Assessments
September 15, 2014
May 15, 2015
F
17 ‐ End of 2nd Six week grading pd.
(mailed 2 days after this date)
April 2, 2015
S M T W T
6 1 2 3 13 4 5 6 7 8 9 10 20 11 12 13 14 15 16 17 27 18 19 20 21 22 23 24 25 26 27 28 29 30 31
25 ‐ Full Day all staff in‐service
Progress Reports
February 10, 2015
S
1 2 3 4 8 9 10 11 15 16 17 18 22 T 23 T 24 25 29 30 31
Student/Staff Holiday
(Unless more than 2 make‐up days required)
S M T W T
2 3 4 5 6 9 10 11 12 13 5 6 7 16 17 18 19 20 12 13 14 23 24 25 26 27 19 20 T 21 T 30 26 27 28
S M T W T 3 10 17 24 31
4 11 18 25
5 12 19 26
6 13 20 27
JUNE 2015 F
1 7 8 14 15 21 22 28 29
S
S M T W T
2 1 2 3 9 7 8 9 10 16 14 15 16 17 23 21 22 23 24 30 28 29 30
JULY 2015 F
4 5 11 12 18 19 25 26
S
S M T W T
6 13 5 6T 7T 20 12 13 14 27 19 20 21 26 27 28
1
2 8T 9T 15 16 22 23 29 30
F
S
3 10 17 24 31
4 11 18 25
May 1, 2015
4‐8 ‐ STAAR Assessments
8 ‐ Last Day of School
June 15, 2015
12‐ STAAR Assessment
8 ‐ End of 6th Six weeks grading pd.
7 ‐ STAAR & TAKS Assessments
15 ‐ STAAR Assessment Make‐up
9 ‐ Full Day all staff in‐service
8‐ STAAR & TAKS Assessments
180 Student Instructional Full Days
Trinity Charter School 8305 Cross Park Drive Austin, Texas 78754
6 ‐ STAAR & TAKS Assessment
15 ‐ Progress Reports
10‐11 ‐ *Bad weather make‐up day
9 ‐ TAKS Assessment
25 ‐ Memorial Day Holiday
23‐ STAAR Assessment
10 ‐ STAAR Assessments
26 ‐ STAAR Assessment Make‐up
512‐459‐1000 www.trinitycharterschools.org
BOARD APPROVED 7/30/2014
Revised 071814
2014-2015 School Calendar AUGUST 2014 S M T W T F 3
4
5
6
7
SEPTEMBER 2014
OCTOBER 2014
S S M T W T F
S S M T W T F
S
1
2
6
4
8
9
7
1
2
3
4
5
8
9
10 11 12 13
5
6
7
1
2
3
8
9
10 11
10 11 12 13 14 15 16 14 15 16 17 18 19 20 12 13+ 14 15 16 17 18 17 18 19 20 21 22 23 21 22 23 24 25 26 27 19 20 T 21 T 22 T 23 T 24 25 24
LEGEND
n
25n
26 27 28 29 30 28 29 30
26 27 28 29 30 31
31
Student/Staff Holiday
18-22 - Full Day all staff in-service
1 - Labor Day Holiday
6 - End of 1st Six week grading pd.
(unless it is a specified In-Service day)
25 - First day of school
15 - Progress Reports
20-23 TAKS Exit Level Assessments 27 - Progress Reports
First/Last day of classes (Unless more than 2 make-up days required)
Full Day All Staff In-service
NOVEMBER 2014 S M T W T F
DECEMBER 2014 S S M T W T F
S S M T W T F
S
1
6
(7:30 a.m. - 3:30 pm)
+ Bad Weather Make-Up Day *School in session only if needed
4
5
6
JANUARY 2015
7
8
1 2 3 4 5 7
8
9
10 11 12 13
T TAKS Assessment
6
7
3
8
9
10
3
9
10 11 12 13 14 15 14 15 16 17 18 19 20 11 12 13 14 15 16 17
16 17 18 19 20 21 22 21 22 23 24 25 26 27 18 19 20 21 22 23+ 24 25 26 27 28 29 30 31
30 17 - End of 2nd Six week grading pd.
1-5 - STAAR Assessments
1 - Winter Break Holiday
25 - Full Day all staff in-service
5 - Make-up date for STAAR English
2 - Full day all staff in-service
26-28 - Thanksgiving Holiday
12 - Progress Reports
16 - End of 3rd Six weeks grading pd.
22-31 - Winter Break Holiday
19 - MLK Day Holiday
Progress Reports
20 - Full day all staff in-service
(mailed 2 days after this date)
FEBRUARY 2015
September 15, 2014
MARCH 2015
APRIL 2015
October 27, 2014
S M T W T F
S S M T W T F
S S M T W T F
S
December 12, 2014
1
2
7
1
7
4
February 10, 2015
8
9 10 11 12 13 14
8
April 2, 2015
15 16 17 18 19 20 21 15 16 17 18 19+ 20 21 12 13 14 15 16 17 18
May 15, 2015
22 23 24 25 26 27 28 22 23 24 25 26 27 28 19 20 2122 23 24 25
3
4
5
6
2 T 3 T 4 T 5T 9
6
10 11 12 13 14
29 3031 Six Week Grading Period Ends
1 2 3 5
6
7
8
9
10 11
26 27 28 29 30
10 - Progress Reports
2-5 - TAKS Assessment
1 - STAAR Assessment
1st Six Weeks - October 6, 2014
16 - President's Day
5 - End of 4th Six weeks grading pd.
2 - STAAR Assessment Make up
2nd Six Weeks - November 17, 2014
17 - Full Day all staff in-service
9-13 - Spring Break Holiday
3 - Good Friday Holiday
30-31 - STAAR Assessments
21-22 - STAAR Assessments
3rd Six Weeks - January 16, 2015
24 - End of 5th Six weeks grading pd.
4th Six Weeks - March 5, 2015
MAY 2015
5th Six Weeks - April 24, 2015 6th Six Weeks - June 8, 2015
JUNE 2015
S M T W T F
Report cards mailed
3
4 5 6 7 8
JULY 2015
S S M T W T F
1+ 2
+
5
2
2
23 24+ 25 26 27 28 29 28 29 30 31
STAAR Assessment
4
1
1
2
3
4
5
S S M T W T F
S
6
4
1
2
3
9
October 13, 2014
7 8n 9 10+ 11+ 12 13 5 6T 7T 8T 9T 10 11 10 11 12 13 14 15 16 14 15+ 16 17 18 19 20 12 13 14 15 16 17 18
November 24, 2014
17 18 19 20 21 22 23 21 22 23 24 25 26 27 19 20 21 22 23 24 25
January 23, 2015
24 25 26 27 28 29 30 28 29 30
March 19, 2015
31
26 27 28 29 30 31
May 1, 2015
4-8 - STAAR Assessments
8 - Last Day of School
6 - STAAR & TAKS Assessment
June 15, 2015
12- STAAR Assessment
8 - End of 6th Six weeks grading pd.
7 - STAAR & TAKS Assessments
15 - STAAR Assessment Make-up
9 - Full Day all staff in-service
8- STAAR & TAKS Assessments
15 - Progress Reports
10-11 - *Bad weather make-up day
9 - TAKS Assessment
25 - Memorial Day Holiday
23- STAAR Assessment
10 - STAAR Assessments
180 Student Instructional Full Days
Trinity Charter School 8305 Cross Park Drive Austin, Texas 78754
26 - STAAR Assessment Make-up
512-459-1000 www.trinitycharterschools.org
BOARD APPROVED 7/30/2014
Revised 072014
INTRODUCTORY PERIOD (90 DAYS) New employees are in an introductory period during their first three months of employment. During this Introductory Period, an employee has an opportunity to get acquainted with his or her job, other employees and Trinity Charter School as an employer. Likewise, Trinity Charter School has an opportunity to evaluate the employee’s job performance and to assist the employee in correcting performance and work standard deficiencies. During the Introductory Period, the following applies: Vacation leave accrues from the date of hire and is available as it accrues. Accrued vacation may be used by the employee during the Introductory Period. Sick leave accrues from the date of hire but is not available to be used by the employee until the completion of the Introductory Period. Upon completion of the Introductory Period, the employee will be subject to a performance evaluation by his or her supervisor. Health Benefits shall begin from date of hire, subject to any introductory period required by particular benefit plan. The Introductory Period for any employee may be extended in the discretion of the employee’s supervisor and normally such an extension will be from one to three months. The employee will be notified in writing of any extension of the Introductory Period. In such cases, a performance evaluation will be complete at the end of the original Introductory Period and another will be completed at the end of the extension. Completion of an Introductory Period does not mean that employment with Trinity Charter School is guaranteed for any specific duration nor does it alter the at-will status of any employee. I have read and understand the Introductory Period (Employee Handbook, Section 3) and agree to its terms.
Employee’s Signature
Date
BENEFIT SUMMARY – 2014-2015
DAYS PER SCHOOL YEAR Number of Workdays
PERSONAL LEAVE
SICK
3 days
5 days
190, 195 Personal Leave 1st year
Personal Leave 2nd year
SICK
206, 210, 220
7 days
7 days
7 days
250
15 days
20 days
10 days
Administrative Positions
Please Note: The carryover date for campus staff is August 10th and the carryover date for central office staff is September 1st. Employees may carryover available unused leave, but not to exceed one school years earnings
HOLIDAYS **All TCS employees work according to a board approved calendar. New Life, Krause, Bokenkamp and Pegasus campuses will observe the following Holiday Breaks** Labor Day (September 1) Thanksgiving Break (November 26 - 28) Christmas Break (December 22 - December 31) New Year's Day (January 1-2) MLK Day (January 19) *Presidents Day (February 16) Spring Break (March 9 - March 13) *Good Friday (April 3) Memorial Day (May 25)
***Central Staff work 250 calendar days, and will observe the following Holiday Breaks** Labor Day (September 1) Thanksgiving Day, the day after Thanksgiving Day (November 27 & 28) Christmas Eve and Christmas Day (December 24 & 25) New Year's Day (January 1) MLK Day (January 19) Good Friday (April 3) Memorial Day (May 25) Independence Day (July 4)
**Employees who normally work Monday-Friday will observe Good Friday instead of Easter Sunday**
TRS-ACTIVE CARE
Group health insurance coverage is provided through TRS-ActiveCare, the statewide public school health insurance program. Employees eligible for health insurance coverage include the following: Employees who are active, contributing TRS members
Employees who are regularly scheduled to work at least 10 hours per week
The insurance plan year is from September 1st through August 31st. New hires must enroll within 31days from their hire date. New hires have 2 options for the effective date of health coverage: 1) Actively at work date 2) First of the month following the actively at work date Effective Date of Rate Changes: 09/01/2014 2014-2015 Monthly Premium Rates (Out-of-Pocket): All enrollees in TRS-ActiveCare 3 will be transitioned to TRS-ActiveCare 2 effective September 1, 2014, unless the employees select another TRS-ActiveCare plan option during the annual enrollment periods for the 2014-15 plan year.
ActiveCare 1 HD
Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
2013-14 $325.00 $794.00 $572.00 $1060.00
TRS Select Plan
2014-15 $325.00 $850.00 $572.00 $1145.00
2013-14 N/A N/A N/A N/A
FirstCare
Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
2013-14 $391.50 $985.06 $607.86 $994.84
2014-15 $390.14 $977.76 $618.94 $987.44
ActiveCare 2
2014-15 $450.00 $1044.00 $709.00 $1238.00
2013-14 $529.00 $1203.00 $841.00 $1323.00
2014-15 $555.00 $1287.00 $875.00 $1323.00
Scott & White 2013-14 $418.42 $945.10 $664.00 $1048.54
ActiveCare 3
2014-15 $452.80 $1020.08 $717.32 $1131.50
2013-14 $523.50 $1537.50 $996.50 $1717.50
2014-15 N/A N/A N/A N/A
Valley Baptist 2013-14 $387.06 $941.04 $607.86 $960.14
2014-15 $400.20 $969.60 $627.14 $989.22
TCS Employer Benefit Contribution per Month - $272.50 TRS-RETIREMENT PLANS All personnel employed on a regular basis for at least 10 hours per week work schedule are members of the Teacher Retirement System of Texas (TRS). Substitutes not receiving TRS service retirement benefits who work at least 90 days a year are also eligible for TRS membership and to purchase a year of creditable service. TRS provides members with an annual statement of their account showing all deposits and the total account balance for the year ending August 31, as well as an estimate of their retirement benefits. Information on the application procedures for TRS benefits is available at central office. Additional inquiries should be addressed to: Teacher Retirement System of Texas, 1000 Red River Street, Austin, TX 78701-2698, or call 800-223-8778 or 512-542-6400. TRS information is also available on the Web (www.trs.state.tx.us). PAYROLL DEDUCTION Automatic payroll deductions for the Teacher Retirement System of Texas (TRS), federal income tax and Medicare are required for all full-time employees. Temporary and part-time employees not eligible for TRS membership must have Social Security contributions deducted. The employees' share of premiums for TRS ActiveCare Health Insurance is payroll deducted. DIRECT DEPOSIT Direct deposit to a checking or saving account is available for your payroll check. For more information regarding direct deposit, please contact the payroll department at 512-706-7566. *Note: Direct deposit is only for Full Time Employees. WORKERS' COMPENSATION Trinity Charter School (TCS) does not subscribe to Workers' Compensation. TCS does provide employee injury benefits to employees who suffer a work-related illness or are injured on the job, as a non-subscriber. Please see campus Principal or your HR representative for further information. Employee Injury & Compliance Coordinator - Sheila Wadley is also available to answer any questions
[email protected] or (512)706-7542.
Acknowledgement
I acknowledge receipt of this Employee handbook. I understand that it is intended for informational purposes. This Handbook in no way insinuates or communicates an employee has entered into a contract or term of employment with Trinity Charter School. No oral or written promise has been made, and no employee of Trinity Charter School has the authority to enter into any such contract except the President and Superintendent of Trinity Charter School. All the information I will need during my employment is not included in this policy manual. It is intended to communicate general policies and benefit information currently in effect. It is my responsibility to ask questions and seek more detailed information as needed. I understand management is committed to reviewing policies, procedures, and benefits continually in order to comply with changing legal requirements and in order to maintain a competitive status in the industry. Accordingly, the contents of this policy manual are subject to review and change by management at any time and without prior notice or discussion. I understand I will receive information through various notices as well as through departmental meetings and information available on the intranet. I understand that I have the right to terminate my employment at any time and for any reason and that the Trinity Charter School has that same right.
_____________________________________ Employee Name (Please Print)
_____________________________________ Employee signature
_____________________ Date
_____________________________________ Witness
_____________________ Date
8/7/2014
Statute: 20 U.S.C. § 1232g Regulations: 34 CFR Part 99
FERPA basics Key FERPA definitions Exceptions to FERPA’s general consent rule Interactions between FERPA and other la
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FERPA is the Federal law that protects the privacy of students’ education records. FERPA applies to educational agencies and institutions that receive funds under any program administered by the Secretary of Education. § 99.1. Most private and parochial schools at the elementary and secondary levels do not receive such funds and are, therefore, not subject to FERPA.
Right to inspect and review education records. Right to seek to amend education records. Right to consent to the disclosure of information from education records, except as provided by law.
These rights under FERPA transfer to the student when he or she turns 18 years of age or enters a postsecondary institution at any age (“eligible student”).
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“Education records” are records that are – (1) (2)
Directly related to a student; and Maintained by an educational agency or institution or by a party acting for the agency or institution.
§ 99.3 “Education records”
Records on a student receiving services under Part B of the Individuals with Disabilities Education Act (IDEA) are “education records” subject to FERPA. Medical or health related records are “education records” subject to FERPA.
Exceptions to “education records” include – Records created and maintained by a law enforcement unit for a law enforcement purpose. Medical and psychological treatment records of eligible students if they are made, maintained, and used only in connection with treatment of the student and disclosed only to professionals providing the treatment.
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8/7/2014
“Personally identifiable information” (PII) includes, but is not limited to: The student’s name; The name of the student’s parent or other family
members;
A personal identifier, such as the student’s social
security number, student number, or biometric record;
Other indirect identifiers, such as the student’s date of
birth, place of birth, and mother’s maiden name;
Other information that, alone or in combination, is
linked or linkable to a specific student that would allow a reasonable person in the school community, who does not have personal knowledge of the relevant circumstances, to identify the student with reasonable certainty; or Information requested by a person who the educational agency or institution reasonably believes knows the identity of the student to whom the education records relates. § 99.3
“Directory information” is –
Information not generally considered harmful or an invasion of privacy if disclosed. Includes, but is not limited to: name, address, telephone listing, electronic mail address date and place of birth, photographs participation in official recognized activities and sports field of study weight and height of athletes enrollment status (full-,part-time, undergraduate, graduate) degrees & awards received dates of attendance
most previous school attended grade level
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“Directory information” cannot generally include a student’s social security number of student ID number. A student’s ID number may be designated as “directory information” when the ID cannot, alone, be used to access education records. § 99.3
“Student” means any individual –
who is or has been in attendance at a school; and regarding whom the school maintains education records.
§ 99.3
§ 99.10 What rights exist for a parent or eligible student to inspect and review education records?
School must comply with request within 45 days.
Generally required to give copies only if failure to do so would effectively deny access – example would be a student or former student who does not live within commuting distance.
School may not destroy records if request for access is pending.
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§ 99.30 Under what conditions is prior consent required to disclose information?
Except for specific exceptions, a parent or eligible student shall provide a signed and dated written consent before a school may disclose education records. The consent must: Specify records that may be disclosed; State the purpose of disclosure; and Identify the party or class of parties to whom disclosure may
be made.
§ 99.31 Under what conditions is prior consent not required to disclose information? The exceptions which relate to K-12 schools and school districts are: To school officials with legitimate educational interests
(defined in the school’s annual notification).
To schools in which a student seeks or intends to enroll. To Federal, State, and local educational authorities conducting
an audit, evaluation, or enforcement of education programs.
Exceptions, cont.
To organizations conducting studies for or on behalf of the school. To parents of a dependent student. To comply with a judicial order or subpoena (reasonable effort to notify). In connection with a health or safety emergency. Directory information. To State and local officials in connection with serving the student under the juvenile justice system (established by State law).
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§ 99.31(a)(1) The disclosure is to school officials, including teachers, within the agency or institution whom the agency or institution has determined to have legitimate educational interests. Criteria for who is considered a “school official” and what is a “legitimate educational interest” must be include in annual notification of rights to parents and students currently in attendance. § 99.7
A contractor, consultant, volunteer, or other party to whom an agency or institution has outsourced institutional services or functions may be considered a “school official” under FERPA provided that the outside party – Performs an institutional service or function for which the agency or institution would otherwise use employees; Is under the direct control of the agency or institution with respect to the use and maintenance of education records; and Is subject to the requirements of § 99.33(a) governing the use and redisclosure of PII from education records.
§ 99.36 What conditions apply to disclosure of information in health or safety emergencies? Disclosure must be to appropriate parties in connection with an emergency if knowledge of information is necessary to protect the health or safety of the student or others. “Appropriate parties” may include parents of an eligible student.
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If school determines that there is an articulable and significant threat to the health or safety of a student or other individuals, it may disclose information from education records to any party whose knowledge of the information is necessary to protect the health or safety of the student or other individuals. If, based on the information available at the time, there is a rational basis for the determination, the Department will not substitute its judgment for that of the school’s in evaluating the circumstances and making its determination.
An educational agency or institution must record the following information when it discloses PII under the health or safety emergency exception in FERPA:
The articulable and significant threat to the health or safety of a student or other individuals that form the basis for the disclosure; and The parties to whom the institution disclosed the information.
§ 99.32(a)(5)
§ 99.31(a)(6) The disclosure is to organizations conducting studies for, or on behalf of, educational agencies or institutions to: Develop, validate, or administer predictive tests; Administer student aid programs; or Improve instruction.
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The school must have a written agreement with the receiving organization that: Specifies the purpose, scope and duration of the study or studies and the information to be disclosed; Requires the organization to use information only to meet the purpose of the study; Requires the organization to conduct the study in a manner that does not permit PII of parents and students by anyone other than organization representatives with legitimate interests; Requires the organization to destroy or return all PII when no longer needed for purposes of the study; and Specifies the time period in which the information must be returned or destroyed.
§ 99.33 What limitations apply to the redisclosure of information?
When disclosing information from education records to one of the parties listed under § 99.31, a school should inform the receiving party that the information may not be further disclosed, except when: The receiving party discloses information on behalf of the
school under § 99.31.
• The disclosure was made pursuant to a court order, subpoena, or in connection with litigation between the school and parent/student. • The disclosure is to the parent or eligible student. • The disclosure is to the parents of a dependent student. • The information disclosed is directory information.
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Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule
Educational institutions that provide health or medical services to students may qualify as “covered entities” under the HIPAA Privacy Rule. However, the HIPAA Privacy Rule specifically excludes from its coverage those records that are protected by FERPA. See definition of “Protected health information” in 45 CFR
45 CFR § 160.103
Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to Student Health Records (November 2008)
http://www2.ed.gov/policy/gen/guid/fpco/do c/ferpa-hipaa-guidance.pdf
Individuals with Disabilities Education Act (IDEA) – IDEA has additional or separate confidentiality requirements in addition to FERPA:
Part B – 34 CFR § 300.610 - § 300.627. Part C – 34 CFR § 303.402 and § 303.460.
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Federal Child Abuse Prevention and Treatment Act (CAPTA).
Provides that a State must have a State law that provides for the reporting of known or suspected instances of child abuse and neglect in order to receive a grant for child abuse prevention and treatment programs.
Protection of Pupil Rights Amendment (PPRA)
PPRA governs the administration to students of a survey, analysis, or evaluation that concerns one or more of the following eight protected areas: Political affiliations or beliefs of the student or the student’s parent; Mental or psychological problems of the student or the student’s family; Sex behavior or attitudes; Illegal, anti-social, self-incriminating, or demeaning behavior; Critical appraisals of other individuals with whom respondents have close family relationships; Legally recognized privileged or analogous relationships, such as those of lawyers, physicians, and ministers; Religious practices, affiliations, or beliefs of the student or student’s parents; or Income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program).
PPRA requires that schools offer parents an opportunity to opt their children out of participating in the following activities: The administration of any survey containing one or more of the 8 areas of information listed previously. (Must contain prior written consent before a minor is required to take a survey containing one or more of the 8 areas of information that is funded in whole or in part with Department funds.) Certain non-emergency, invasive physical examination or screenings. Activities involving the collection, disclosure, or use of personal information collected from students for the purpose of marketing or for selling. 20 U.S.C. § 1232h; 34 CFR Part 98
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Q. 1. Which law – FERPA or the HIPAA Privacy Rule – governs records on health care delivered through a school-based health center when the center is organized and implemented by the school district? A. 1. Any records that a school nurse or health center maintains that are directly related to a student are considered “education records” subject to FERPA. This issue was explained in our joint guidance on FERPA and HIPAA, and reiterated in the guidance on FERPA and H1N1. If a person or entity is acting on behalf of a school subject to FERPA, such as a school nurse who is under contract with, is an employee of, or is otherwise under the direct control of the school, their student health records are “education records” subject to FERPA. This is the case regardless of whether the health care is provided to students on school grounds or offsite.
Q.2. What latitude do school nurses or school administrators have in divulging information about teen pregnancy to parents/guardians? Does the pregnant student have the right to refuse schools to notify their parents? A.2. Schools are not prohibited by FERPA from disclosing information about teen pregnancy to parents, even if the teen requests that the parents not be notified. In fact, if a parent requests to inspect and review records maintained by the school nurse on their minor child, FERPA would require the school official to provide the parents with an opportunity to review the records. Personal knowledge and observation are not governed by FERPA.
Q.3. How should conflicts among Federal and State laws, organizational policies, and professional ethical codes addressing confidentiality be resolved? A.3. FPCO routinely reviews potential conflicts with FERPA. In fact, school officials are required to report potential conflicts to FPCO within 45 days of making a determination there is such a conflict. Often times, what school officials believe are conflicts are not and we can provide advice on how to address the matter. Ultimately, however, if there is a conflict and a school wishes to continue to receive U.S. Department of Education funds, it must comply with FERPA.
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Q.4. If a school wants to contact a child’s doctor about an inaccuracy on an excuse note, do we need any special permission or may we contact the doctor directly? A.4. Under FERPA, the 2008 regulations changed the definition of “disclosure” to permit a school to contact the stated source of a record (such as a doctor’s note) for verification purposes. This is not considered a disclosure and, therefore, does not violate FERPA. In other words, FERPA permits a targeted release of records back to the stated source for verification purposes in order to provide schools with flexibility needed for this process while preserving a more general prohibition on the release of information from education records. I understand that, under the HIPAA Privacy Rule, it would depend on how the doctor’s note is addressed in order for the doctor to respond to the inquiry. If it is addressed to the school or a school official, then HIPAA would permit it to be verified as well. However, if it is a generic note, the school could demand that consent be given for the doctor to disclose the information before agreeing to the student being legitimately absent that day. In a situation in which there is no doctor’s excuse note where a school officials wishes to call a student’s doctor and discuss the student’s medication, restrictions, etc., the parent must provide written consent before the school official calls the doctor and discloses information from the student’s education records.
Q.5. May health records or other education records maintained by a school be disclosed, without consent, to the public health department? A.5. Yes, if the disclosure meets the conditions for FERPA’s health or safety emergency exception to the general consent rule. If school officials, taking into account the totality of the circumstances, determine that an articulable and significant threat exists to the health or safety of a student or other individuals, they may disclose PII from education records to appropriate officials, without consent, who need the information to protect the health or safety of the student of other individuals. Typically public health officials and trained medical personnel are among the types of appropriate parties to whom information may be disclosed under FERPA’s health or safety emergency provision.
FERPA regulations: http://www2.ed.gov/policy/gen/reg/ferpa/index.html FERPA & H1N1: http://www2.ed.gov/policy/gen/guid/fpco/pdf/ferpa-h1n1.pdf FERPA & Emergencies & Other Disasters: http://www2.ed.gov/policy/gen/guid/fpco/pdf/ferpa-disasterguidance.pdf Amendments to FERPA regulations (2008): http://www2.ed.gov/legislation/FedRegister/finrule/20084/120908a.pdf
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U.S. Department of Health and Human Services
U.S. Department of Education
Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) And the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records
November 2008
Contents I. Introduction ........................................................................................................................ 1 II. Overview of FERPA …………………………………………………………………….. 1 III. Overview of HIPAA ……………………………………………………………………... 2 IV. Where FERPA and HIPAA May Intersect …………………………………………….. 3 V. Frequently Asked Questions and Answers …………………………………………….. 3 1. Does the HIPAA Privacy Rule apply to an elementary or secondary school? 2. How does FERPA apply to health records on students maintained by elementary or secondary schools? 3. Does FERPA or HIPAA apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? 4. Are there circumstances in which the HIPAA Privacy Rule might apply to an elementary or secondary school? 5. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a troubled teen to the parents of the teen? 6. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a student to a school nurse or physician? 7. Does FERPA or HIPAA apply to records on students at health clinics run by postsecondary institutions? 8. Under FERPA, may an eligible student inspect and review his or her “treatment records”? 9. Under FERPA, may an eligible student’s treatment records be shared with parties other than treating professionals? 10. Under what circumstances does FERPA permit an eligible student’s treatment records to be disclosed to a third-party health care provider for treatment? 11. Are all student records maintained by a health clinic run by a postsecondary institution considered “treatment records” under FERPA? 12. Does FERPA or HIPAA apply to records on students who are patients at a university hospital? 13. Where the HIPAA Privacy Rule applies, does it permit a health care provider to disclose protected health information (PHI) about a patient to law enforcement, family members, or others if the provider believes the patient presents a serious danger to self or others? 14. Does FERPA permit a postsecondary institution to disclose a student’s treatment records or education records to law enforcement, the student’s parents, or others if the institution believes the student presents a serious danger to self or others? 15. Are the health records of an individual who is both a student and an employee of a university at which the person receives health care subject to the privacy provisions of FERPA or those of HIPAA? 16. Can a postsecondary institution be a “hybrid entity” under the HIPAA Privacy Rule? VI.
Conclusion ……………………………………………………………………………… 11
I.
Introduction
The purpose of this guidance is to explain the relationship between the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule, and to address apparent confusion on the part of school administrators, health care professionals, and others as to how these two laws apply to records maintained on students. It also addresses certain disclosures that are allowed without consent or authorization under both laws, especially those related to health and safety emergency situations. While this guidance seeks to answer many questions that school officials and others have had about the intersection of these federal laws, ongoing discussions may cause more issues to emerge. Contact information for submitting additional questions or suggestions for purposes of informing future guidance is provided at the end of this document. The Departments of Education and Health and Human Services are committed to a continuing dialogue with school officials and other professionals on these important matters affecting the safety and security of our nation’s schools. II.
Overview of FERPA
FERPA is a Federal law that protects the privacy of students’ “education records.” (See 20 U.S.C. § 1232g; 34 CFR Part 99). FERPA applies to educational agencies and institutions that receive funds under any program administered by the U.S. Department of Education. This includes virtually all public schools and school districts and most private and public postsecondary institutions, including medical and other professional schools. If an educational agency or institution receives funds under one or more of these programs, FERPA applies to the recipient as a whole, including each of its components, such as a department within a university. See 34 CFR § 99.1(d). Private and religious schools at the elementary and secondary level generally do not receive funds from the Department of Education and are, therefore, not subject to FERPA. Note that a private school is not made subject to FERPA just because its students and teachers receive services from a local school district or State educational agency that receives funds from the Department. The school itself must receive funds from a program administered by the Department to be subject to FERPA. For example, if a school district places a student with a disability in a private school that is acting on behalf of the school district with regard to providing services to that student, the records of that student are subject to FERPA, but not the records of the other students in the private school. In such cases, the school district remains responsible for complying with FERPA with respect to the education records of the student placed at the private school. An educational agency or institution subject to FERPA may not have a policy or practice of disclosing the education records of students, or personally identifiable information from education records, without a parent or eligible student’s written consent. See 34 CFR § 99.30. FERPA contains several exceptions to this general consent rule. See 34 CFR § 99.31. An “eligible student” is a student who is at least 18 years of age or who attends a postsecondary institution at any age. See 34 CFR §§ 99.3 and 99.5(a). Under FERPA, parents and eligible students have the right to inspect and review the student’s education records and to seek to have them amended in certain circumstances. See 34 CFR §§ 99.10 – 99.12 and §§ 99.20 – 99.22. The term “education records” is broadly defined to mean those records that are: (1) directly related to a student, and (2) maintained by an educational agency or institution or by a party acting for the 1
agency or institution. See 34 CFR § 99.3. At the elementary or secondary level, a student’s health records, including immunization records, maintained by an educational agency or institution subject to FERPA, as well as records maintained by a school nurse, are “education records” subject to FERPA. In addition, records that schools maintain on special education students, including records on services provided to students under the Individuals with Disabilities Education Act (IDEA), are “education records” under FERPA. This is because these records are (1) directly related to a student, (2) maintained by the school or a party acting for the school, and (3) not excluded from the definition of “education records.” At postsecondary institutions, medical and psychological treatment records of eligible students are excluded from the definition of “education records” if they are made, maintained, and used only in connection with treatment of the student and disclosed only to individuals providing the treatment. See 34 CFR § 99.3 “Education records.” These records are commonly called “treatment records.” An eligible student’s treatment records may be disclosed for purposes other than the student’s treatment, provided the records are disclosed under one of the exceptions to written consent under 34 CFR § 99.31(a) or with the student’s written consent under 34 CFR § 99.30. If a school discloses an eligible student’s treatment records for purposes other than treatment, the records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements. The FERPA regulations and other helpful information can be found at: http://www.ed.gov/policy/gen/guid/fpco/index.html. III.
Overview of HIPAA
Congress enacted HIPAA in 1996 to, among other things, improve the efficiency and effectiveness of the health care system through the establishment of national standards and requirements for electronic health care transactions and to protect the privacy and security of individually identifiable health information. Collectively, these are known as HIPAA’s Administrative Simplification provisions, and the U.S. Department of Health and Human Services has issued a suite of rules, including a privacy rule, to implement these provisions. Entities subject to the HIPAA Administrative Simplification Rules (see 45 CFR Parts 160, 162, and 164), known as “covered entities,” are health plans, health care clearinghouses, and health care providers that transmit health information in electronic form in connection with covered transactions. See 45 CFR § 160.103. “Health care providers” include institutional providers of health or medical services, such as hospitals, as well as non-institutional providers, such as physicians, dentists, and other practitioners, along with any other person or organization that furnishes, bills, or is paid for health care in the normal course of business. Covered transactions are those for which the U.S. Department of Health and Human Services has adopted a standard, such as health care claims submitted to a health plan. See 45 CFR § 160.103 (definitions of “health care provider” and “transaction”) and 45 CFR Part 162, Subparts K–R. The HIPAA Privacy Rule requires covered entities to protect individuals’ health records and other identifiable health information by requiring appropriate safeguards to protect privacy, and setting limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections.
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IV.
Where FERPA and HIPAA May Intersect
When a school provides health care to students in the normal course of business, such as through its health clinic, it is also a “health care provider” as defined by HIPAA. If a school also conducts any covered transactions electronically in connection with that health care, it is then a covered entity under HIPAA. As a covered entity, the school must comply with the HIPAA Administrative Simplification Rules for Transactions and Code Sets and Identifiers with respect to its transactions. However, many schools, even those that are HIPAA covered entities, are not required to comply with the HIPAA Privacy Rule because the only health records maintained by the school are “education records” or “treatment records” of eligible students under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule. See the exception at paragraph (2)(i) and (2)(ii) to what is considered “protected health information” (PHI) at 45 CFR § 160.103. In addition, the exception for records covered by FERPA applies both to the HIPAA Privacy Rule, as well as to the HIPAA Security Rule, because the Security Rule applies to a subset of information covered by the Privacy Rule (i.e., electronic PHI). Information on the HIPAA Privacy Rule is available at: http://www.hhs.gov/ocr/hipaa/. Information on the other HIPAA Administrative Simplification Rules is available at: http://www.cms.hhs.gov/HIPAAGenInfo/. V.
Frequently Asked Questions and Answers
1.
Does the HIPAA Privacy Rule apply to an elementary or secondary school?
Generally, no. In most cases, the HIPAA Privacy Rule does not apply to an elementary or secondary school because the school either: (1) is not a HIPAA covered entity or (2) is a HIPAA covered entity but maintains health information only on students in records that are by definition “education records” under FERPA and, therefore, is not subject to the HIPAA Privacy Rule. •
The school is not a HIPAA covered entity. The HIPAA Privacy Rule only applies to health plans, health care clearinghouses, and those health care providers that transmit health information electronically in connection with certain administrative and financial transactions (“covered transactions”). See 45 CFR § 160.102. Covered transactions are those for which the U.S. Department of Health and Human Services has adopted a standard, such as health care claims submitted to a health plan. See the definition of “transaction” at 45 CFR § 160.103 and 45 CFR Part 162, Subparts K–R. Thus, even though a school employs school nurses, physicians, psychologists, or other health care providers, the school is not generally a HIPAA covered entity because the providers do not engage in any of the covered transactions, such as billing a health plan electronically for their services. It is expected that most elementary and secondary schools fall into this category.
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The school is a HIPAA covered entity but does not have “protected health information.” Where a school does employ a health care provider that conducts one or more covered transactions electronically, such as electronically transmitting health care claims to a health plan for payment, the school is a HIPAA covered entity and must comply with the HIPAA Transactions and Code Sets and Identifier Rules with respect to such transactions. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health information only in student health records that are “education records” under FERPA and, thus, not “protected health information” under
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HIPAA. Because student health information in education records is protected by FERPA, the HIPAA Privacy Rule excludes such information from its coverage. See the exception at paragraph (2)(i) to the definition of “protected health information” in the HIPAA Privacy Rule at 45 CFR § 160.103. For example, if a public high school employs a health care provider that bills Medicaid electronically for services provided to a student under the IDEA, the school is a HIPAA covered entity and would be subject to the HIPAA requirements concerning transactions. However, if the school’s provider maintains health information only in what are education records under FERPA, the school is not required to comply with the HIPAA Privacy Rule. Rather, the school would have to comply with FERPA’s privacy requirements with respect to its education records, including the requirement to obtain parental consent (34 CFR § 99.30) in order to disclose to Medicaid billing information about a service provided to a student. 2.
How does FERPA apply to health records on students maintained by elementary or secondary schools?
At the elementary or secondary school level, students’ immunization and other health records that are maintained by a school district or individual school, including a school-operated health clinic, that receives funds under any program administered by the U.S. Department of Education are “education records” subject to FERPA, including health and medical records maintained by a school nurse who is employed by or under contract with a school or school district. Some schools may receive a grant from a foundation or government agency to hire a nurse. Notwithstanding the source of the funding, if the nurse is hired as a school official (or contractor), the records maintained by the nurse or clinic are “education records” subject to FERPA. Parents have a right under FERPA to inspect and review these health and medical records because they are “education records” under FERPA. See 34 CFR §§ 99.10 – 99.12. In addition, these records may not be shared with third parties without written parental consent unless the disclosure meets one of the exceptions to FERPA’s general consent requirement. For instance, one of these exceptions allows schools to disclose a student’s health and medical information and other “education records” to teachers and other school officials, without written consent, if these school officials have “legitimate educational interests” in accordance with school policy. See 34 CFR § 99.31(a)(1). Another exception permits the disclosure of education records, without consent, to appropriate parties in connection with an emergency, if knowledge of the information is necessary to protect the health or safety of the student or other individuals. See 34 CFR §§ 99.31(a)(10) and 99.36. 3.
Does FERPA or HIPAA apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school?
If a person or entity acting on behalf of a school subject to FERPA, such as a school nurse that provides services to students under contract with or otherwise under the direct control of the school, maintains student health records, these records are education records under FERPA, just as they would be if the school maintained the records directly. This is the case regardless of whether the health care is provided to students on school grounds or off-site. As education records, the information is protected under FERPA and not HIPAA.
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Some outside parties provide services directly to students and are not employed by, under contract to, or otherwise acting on behalf of the school. In these circumstances, these records are not “education records” subject to FERPA, even if the services are provided on school grounds, because the party creating and maintaining the records is not acting on behalf of the school. For example, the records created by a public health nurse who provides immunization or other health services to students on school grounds or otherwise in connection with school activities but who is not acting on behalf of the school would not be “education records” under FERPA. In such situations, a school that wishes to disclose to this outside party health care provider any personally identifiable information from education records would have to comply with FERPA and obtain parental consent. See 34 CFR § 99.30. With respect to HIPAA, even where student health records maintained by a health care provider are not education records protected by FERPA, the HIPAA Privacy Rule would apply to such records only if the provider conducts one or more of the HIPAA transactions electronically, e.g., billing a health plan electronically for his or her services, making the provider a HIPAA covered entity. 4.
Are there circumstances in which the HIPAA Privacy Rule might apply to an elementary or secondary school?
There are some circumstances in which an elementary or secondary school would be subject to the HIPAA Privacy Rule, such as where the school is a HIPAA covered entity and is not subject to FERPA. As explained previously, most private schools at the elementary and secondary school levels typically do not receive funding from the U.S. Department of Education and, therefore, are not subject to FERPA. A school that is not subject to FERPA and is a HIPAA covered entity must comply with the HIPAA Privacy Rule with respect to any individually identifiable health information it has about students and others to whom it provides health care. For example, if a private elementary school that is not subject to FERPA employs a physician who bills a health plan electronically for the care provided to students (making the school a HIPAA covered entity), the school is required to comply with the HIPAA Privacy Rule with respect to the individually identifiable health information of its patients. The only exception would be where the school, despite not being subject to FERPA, has education records on one or more students to whom it provides services on behalf of a school or school district that is subject to FERPA. In this exceptional case, the education records of only those publiclyplaced students held by the private school would be subject to FERPA, while the remaining student health records would be subject to the HIPAA Privacy Rule. 5.
Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a troubled teen to the parents of the teen?
In most cases, yes. If the teen is a minor, the HIPAA Privacy Rule generally allows a covered entity to disclose PHI about the child to the child’s parent, as the minor child’s personal representative, when the disclosure is not inconsistent with state or other law. For more detailed information, see 45 CFR § 164.502(g) and the fact sheet regarding personal representatives at: http://www.hhs.gov/ocr/hipaa/guidelines/personalrepresentatives.pdf. In some cases, such as when a minor may receive treatment without a parent’s consent under applicable law, the parents are not treated as the minor’s personal representative. See 45 CFR § 164.502(g)(3). In such cases where 5
the parent is not the personal representative of the teen, other HIPAA Privacy Rule provisions may allow the disclosure of PHI about the teen to the parent. For example, if a provider believes the teen presents a serious danger to self or others, the HIPAA Privacy Rule permits a covered entity to disclose PHI to a parent or other person(s) if the covered entity has a good faith belief that: (1) the disclosure is necessary to prevent or lessen the threat and (2) the parent or other person(s) is reasonably able to prevent or lessen the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR § 164.512(j)(1)(i). In addition, the Privacy Rule permits covered entities to share information that is directly relevant to the involvement of a family member in the patient’s health care or payment for care if, when given the opportunity, the patient does not object to the disclosure. Even when the patient is not present or it is impracticable, because of emergency circumstances or the patient’s incapacity, for the covered entity to ask the patient about discussing his or her care or payment with a family member, a covered entity may share this information with the family member when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient. See 45 CFR § 164.510(b). 6.
Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a student to a school nurse or physician?
Yes. The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school nurses, physicians, or other health care providers for treatment purposes, without the authorization of the student or student’s parent. For example, a student’s primary care physician may discuss the student’s medication and other health care needs with a school nurse who will administer the student’s medication and provide care to the student while the student is at school. 7.
Does FERPA or HIPAA apply to records on students at health clinics run by postsecondary institutions?
FERPA applies to most public and private postsecondary institutions and, thus, to the records on students at the campus health clinics of such institutions. These records will be either education records or treatment records under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule, even if the school is a HIPAA covered entity. See the exceptions at paragraphs (2)(i) and (2)(ii) to the definition of “protected health information” at 45 CFR § 160.103. The term “education records” is broadly defined under FERPA to mean those records that are: (1) directly related to a student and (2) maintained by an educational agency or institution or by a party acting for the agency or institution. See 34 CFR § 99.3, “Education records.” “Treatment records” under FERPA, as they are commonly called, are: records on a student who is eighteen years of age or older, or is attending an institution of postsecondary education, which are made or maintained by a physician, psychiatrist, psychologist, or other recognized professional or paraprofessional acting in his professional or paraprofessional capacity, or assisting in that capacity, and which are made, maintained, or used only in connection with the provision of treatment to the student, and are not available to anyone other than persons providing such treatment, except that such records
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can be personally reviewed by a physician or other appropriate professional of the student’s choice. See 20 U.S.C. § 1232g(a)(4)(B)(iv); 34 CFR § 99.3, “Education records.” For example, treatment records would include health or medical records that a university psychologist maintains only in connection with the provision of treatment to an eligible student, and health or medical records that the campus health center or clinic maintains only in connection with the provision of treatment to an eligible student. (Treatment records also would include health or medical records on an eligible student in high school if the records otherwise meet the above definition.) “Treatment records” are excluded from the definition of “education records” under FERPA. However, it is important to note, that a school may disclose an eligible student’s treatment records for purposes other than the student’s treatment provided that the records are disclosed under one of the exceptions to written consent under 34 CFR § 99.31(a) or with the student’s written consent under 34 CFR § 99.30. If a school discloses an eligible student’s treatment records for purposes other than treatment, the treatment records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements, including the right of the eligible student to inspect and review the records. While the health records of students at postsecondary institutions may be subject to FERPA, if the institution is a HIPAA covered entity and provides health care to nonstudents, the individually identifiable health information of the clinic’s nonstudent patients is subject to the HIPAA Privacy Rule. Thus, for example, postsecondary institutions that are subject to both HIPAA and FERPA and that operate clinics open to staff, or the public, or both (including family members of students) are required to comply with FERPA with respect to the health records of their student patients, and with the HIPAA Privacy Rule with respect to the health records of their nonstudent patients. 8.
Under FERPA, may an eligible student inspect and review his or her “treatment records”?
Under FERPA, treatment records, by definition, are not available to anyone other than professionals providing treatment to the student, or to physicians or other appropriate professionals of the student’s choice. However, this does not prevent an educational institution from allowing a student to inspect and review such records. If the institution chooses to do so, though, such records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements. 9.
Under FERPA, may an eligible student’s treatment records be shared with parties other than treating professionals?
As explained previously, treatment records, by definition, are not available to anyone other than professionals providing treatment to the student, or to physicians or other appropriate professionals of the student’s choice. However, this does not prevent an educational institution from using or disclosing these records for other purposes or with other parties. If the institution chooses to do so, a disclosure may be made to any party with a prior written consent from the eligible student (see 34 CFR § 99.30) or under any of the disclosures permitted without consent in 34 CFR § 99.31 of FERPA.
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For example, a university physician treating an eligible student might determine that treatment records should be disclosed to the student’s parents. This disclosure may be made if the eligible student is claimed as a dependent for federal income tax purposes (see 34 CFR § 99.31(a)(8)). If the eligible student is not claimed as a dependent, the disclosure may be made to parents, as well as other appropriate parties, if the disclosure is in connection with a health or safety emergency. See 34 CFR §§ 99.31(a)(10) and 99.36. Once the records are disclosed under one of the exceptions to FERPA’s general consent requirement, the treatment records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements as “education records” under FERPA. 10.
Under what circumstances does FERPA permit an eligible student’s treatment records to be disclosed to a third-party health care provider for treatment?
An eligible student’s treatment records may be shared with health care professionals who are providing treatment to the student, including health care professionals who are not part of or not acting on behalf of the educational institution (i.e., third-party health care provider), as long as the information is being disclosed only for the purpose of providing treatment to the student. In addition, an eligible student’s treatment records may be disclosed to a third-party health care provider when the student has requested that his or her records be “reviewed by a physician or other appropriate professional of the student’s choice.” See 20 U.S.C. § 1232g(a)(4)(B)(iv). In either of these situations, if the treatment records are disclosed to a third-party health care provider that is a HIPAA covered entity, the records would become subject to the HIPAA Privacy Rule. The records at the educational institution continue to be treatment records under FERPA, so long as the records are only disclosed by the institution for treatment purposes to a health care provider or to the student’s physician or other appropriate professional requested by the student. If the disclosure is for purposes other than treatment, an eligible student’s treatment record only may be disclosed to a third party as an “education record,” that is, with the prior written consent of the eligible student or if one of the exceptions to FERPA’s general consent requirement is met. See 34 CFR § 99.31. For example, if a university is served with a court order requiring the disclosure of the mental health records of a student maintained as treatment records at the campus clinic, the university may disclose the records to comply with the court order in accordance with the provisions of § 99.31(a)(9) of the FERPA regulations. However, the mental health records that the university disclosed for non-treatment purposes are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements as “education records” under FERPA. 11.
Are all student records maintained by a health clinic run by a postsecondary institution considered “treatment records” under FERPA?
Not all records on eligible students that are maintained by a college- or university-run health clinic are treatment records under FERPA because many such records are not made, maintained, or used only in connection with the treatment of a student. For example, billing records that a college- or university-run health clinic maintains on a student are “education records” under FERPA, the disclosure of which would require prior written consent from the eligible student unless an exception applies. See 34 CFR § 99.30. In addition, records relating to treatment that are shared with persons other than professionals providing treatment to the student are “education records” under FERPA. Thus, to the extent a health clinic has shared a student’s treatment information with 8
persons and for purposes other than for treatment, such information is an “education record,” not a treatment record under FERPA. 12.
Does FERPA or HIPAA apply to records on students who are patients at a university hospital?
Patient records maintained by a hospital affiliated with a university that is subject to FERPA are not typically “education records” or “treatment records” under FERPA because university hospitals generally do not provide health care services to students on behalf of the educational institution. Rather, these hospitals provide such services without regard to the person’s status as a student and not on behalf of a university. Thus, assuming the hospital is a HIPAA covered entity, these records are subject to all of the HIPAA rules, including the HIPAA Privacy Rule. However, in a situation where a hospital does run the student health clinic on behalf of a university, the clinic records on students would be subject to FERPA, either as “education records” or “treatment records,” and not subject to the HIPAA Privacy Rule. 13.
Where the HIPAA Privacy Rule applies, does it permit a health care provider to disclose protected health information (PHI) about a patient to law enforcement, family members, or others if the provider believes the patient presents a serious danger to self or others?
The HIPAA Privacy Rule permits a covered entity to disclose PHI, including psychotherapy notes, when the covered entity has a good faith belief that the disclosure: (1) is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others and (2) is to a person(s) reasonably able to prevent or lessen the threat. This may include, depending on the circumstances, disclosure to law enforcement, family members, the target of the threat, or others who the covered entity has a good faith belief can mitigate the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR § 164.512(j)(1)(i). For example, consistent with other law and ethical standards, a mental health provider whose teenage patient has made a credible threat to inflict serious and imminent bodily harm on one or more fellow students may alert law enforcement, a parent or other family member, school administrators or campus police, or others the provider believes may be able to prevent or lessen the chance of harm. In such cases, the covered entity is presumed to have acted in good faith where its belief is based upon the covered entity’s actual knowledge (i.e., based on the covered entity’s own interaction with the patient) or in reliance on a credible representation by a person with apparent knowledge or authority (i.e., based on a credible report from a family member or other person). See 45 CFR § 164.512(j)(4). For threats or concerns that do not rise to the level of “serious and imminent,” other HIPAA Privacy Rule provisions may apply to permit the disclosure of PHI. For example, covered entities generally may disclose PHI about a minor child to the minor’s personal representative (e.g., a parent or legal guardian), consistent with state or other laws. See 45 CFR § 164.502(b). 14.
Does FERPA permit a postsecondary institution to disclose a student’s treatment records or education records to law enforcement, the student’s parents, or others if the institution believes the student presents a serious danger to self or others?
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An eligible student’s education records and treatment records (which are considered education records if used or made available for any purpose other than the eligible student’s treatment) may be disclosed, without consent, if the disclosure meets one of the exceptions to FERPA’s general consent rule. See 34 CFR § 99.31. One of the permitted disclosures is to appropriate parties, which may include law enforcement or parents of a student, in connection with an emergency if knowledge of the information is necessary to protect the health or safety of the student or other individuals. See 34 CFR §§ 99.31(a)(10) and 99.36. There are other exceptions that apply to disclosing information to parents of eligible students that are discussed on the “Safe Schools & FERPA” Web page, as well as other information that should be helpful to school officials, at: http://www.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/index.html/. 15.
Are the health records of an individual who is both a student and an employee of a university at which the person receives health care subject to the privacy provisions of FERPA or those of HIPAA?
The individual’s health records would be considered “education records” protected under FERPA and, thus, excluded from coverage under the HIPAA Privacy Rule. FERPA defines “education records” as records that are directly related to a student and maintained by an educational agency or institution or by a party acting for the agency or institution. 34 CFR § 99.3 (“education records”). While FERPA excludes from this definition certain records relating to employees of the educational institution, to fall within this exclusion, such records must, among other things, relate exclusively to the individual in his or her capacity as an employee, such as records that were created in connection with health services that are available only to employees. Thus, the health or medical records that are maintained by a university as part of its provision of health care to a student who is also an employee of a university are covered by FERPA and not the HIPAA Privacy Rule. 16.
Can a postsecondary institution be a “hybrid entity” under the HIPAA Privacy Rule?
Yes. A postsecondary institution that is a HIPAA covered entity may have health information to which the Privacy Rule may apply not only in the health records of nonstudents in the health clinic, but also in records maintained by other components of the institution that are not education records or treatment records under FERPA, such as in a law enforcement unit or research department. In such cases, the institution, as a HIPAA covered entity, has the option of becoming a “hybrid entity” and, thus, having the HIPAA Privacy Rule apply only to its health care unit. The school can achieve hybrid entity status by designating the health unit as its “health care component.” As a hybrid entity, any individually identifiable health information maintained by other components of the university (i.e., outside of the health care component), such as a law enforcement unit, or a research department, would not be subject to the HIPAA Privacy Rule, notwithstanding that these components of the institution might maintain records that are not “education records” or treatment records under FERPA. To become a hybrid entity, the covered entity must designate and include in its health care component all components that would meet the definition of a covered entity if those components were separate legal entities. (A covered entity may have more than one health care component.) However, the hybrid entity is not permitted to include in its health care component other types of components that do not perform the covered functions of the covered entity or components that do 10
not perform support activities for the components performing covered functions. That is, components that do not perform health plan, health care provider, or health care clearinghouse functions and components that do not perform activities in support of these functions (as would a business associate of a separate legal entity) may not be included in a health care component. Within the hybrid entity, most of the HIPAA Privacy Rule requirements apply only to the health care component, although the hybrid entity retains certain oversight, compliance, and enforcement obligations. See 45 CFR § 164.105 of the Privacy Rule for more information. VI.
Conclusion
The HIPAA Privacy Rule specifically excludes from its coverage those records that are protected by FERPA. When making determinations as to whether personally identifiable information from student health records maintained by the educational agency or institution may be disclosed, school officials at institutions subject to FERPA should refer to FERPA and its requirements. While the educational agency or institution has the responsibility to make the initial, case-by-case determination of whether a disclosure meets the requirements of FERPA, the Department of Education’s Family Policy Compliance Office is available to offer technical assistance to school officials in making such determinations. For quick, informal responses to routine questions about FERPA, school officials may e-mail the Department at
[email protected]. For more formal technical assistance on the information provided in this guidance in particular or FERPA in general, please contact the Family Policy Compliance Office at the following address: Family Policy Compliance Office U.S. Department of Education 400 Maryland Ave. S.W. Washington, D.C. 20202-8520 You may also find additional information and guidance on the Department’s Web site at: http://www.ed.gov/policy/gen/guid/fpco/index.html. For more information on the HIPAA Privacy Rule, please visit the Department of Health and Human Services’ HIPAA Privacy Rule Web site at: http://www.hhs.gov/ocr/hipaa/. The Web site offers a wide range of helpful information about the HIPAA Privacy Rule, including the full text of the Privacy Rule, a HIPAA Privacy Rule summary, over 200 frequently asked questions, and both consumer and covered entity fact sheets. In addition, if you would like to submit additional questions not covered by this guidance document or suggestions for purposes of informing future guidance, please send an e-mail to
[email protected] and
[email protected].
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From: Administration To: All New Hires Ref: HIPPA Privacy Attached are training materials concerning privacy and the Health Insurance Portability and Accountability Act (HIPAA). Health information, medical or insurance related is confidential and protected by Federal Law, the HIPAA Act. Our clients’ information, as well as your own personal information, is only to be used to provide health care and payment of health care operations. Please read the attached HIPAA training materials for an explanation of how you can protect the privacy of health information.
I, _______________________________, have read the training materials and understand (Print name) the agency’s HIPAA rules and regulations.
Signature _________________________________
Date_____________
8305 Cross Park Dr. Austin, TX 78754 512-459-1000, FAX 877-705-2447
TRINITY CHARTER SCHOOL CONFIDENTIALITY AGREEMENT Employees, volunteers, interns and/or subcontractors who work in or with programs and facilities operated by Trinity Charter School (TCS) need and will have access to personal information about clients/students/families. Federal and state laws require that TCS carefully guard all private information. By signing this agreement, you agree to abide by the following conditions and requirements: I will only use private information about clients/students/families as needed to fulfill my assigned job or service. I agree to access and use only the minimum amount of information necessary. I will not seek access to information I do not need. Health information, medical or insurance related is confidential and protected by Federal Law, the HIPAA Act. Our client/student/family information, as well as your own personal information, is confidential and should not be discussed with anyone. I will not disclose this information to others, especially those outside the school. I will not discuss private information unless it is required to conduct my job task. I will not gossip about or inappropriately discuss client/student/family information. I will not sell any client/student/family information. I will not remove client/student/family information in any form from a school. I understand that failure to meet the above standards may constitute grounds for discharge or cancellation of subcontract. I have received a signed copy of this agreement.
__________________________ ________________________ Employee/Volunteer/Sub-contractor Date
__________________________________ Program or Location
__________________________________ TCS Staff Witness
CONFIDENTIALITY STATEMENT FOR COMPUTER PASSWORDS
I have read, understand and will comply with the provisions of Personnel Policy 4.29 – Computer & Information Systems management and 4.36 – Employee Acceptable use. Regarding the use of computer passwords:
I will not use a password, access a file, or retrieve any stored information, unless authorized to do so.
I will not disclose my password to any other person.
I will not sign another person in under my password and let them have access to my computer.
______________________________ Employee’s Signature
_____________ Date
08/14
Trinity Charter School Bloodborne Pathogens Exposure Control Plan Training Record Upon completion of this Trinity Charter School training program, the employee will understand:
Chapter 96. Bloodborne Pathogen Control; OSHA Bloodborne Pathogen Final Rule; A general explanation on of the epidemiology and symptoms of bloodborne disease An explanation of the modes of transmission of bloodborne pathogens An explanation of the Trinity Charter School Exposure Control Plan and where to obtain a copy
An explanation of procedures which might cause exposure to blood or other potentially infectious materials An explanation of the control methods, which are used at the facility to control exposure to blood or other potential infectious materials. An explanation of personal protective equipment available at the facility An explanation of Trinity Charter School hepatitis B vaccine program, information on the HBV vaccine, including its efficacy, safety, and the benefits of being vaccinated. An explanation of procedures to follow in an emergency involving blood or other potentially infectious materials. An explanation of procedures to follow in an exposure incident occurs. An explanation of post exposure evaluation and follow up. An explanation of signs and labels used at the facility. An opportunity to ask question of the individual conducting the training. I have participated in the Trinity Charter School training program on Bloodborne Pathogens and have met the above state objectives. Employee Signature _____________________________________________ Date: __________________ One copy to employee One signed copy to school district HR Office
Bloodborne Pathogens Exposure Control Plan Copies of Plan
Nurse’s Office Principal’s Office Central Office, Risk Management Coordinator
Work Area Practices
No eating, drinking, applying cosmetics, or handling contact lenses Food or beverages are not to be kept in the refrigerators, on shelves or counter tops where blood or OPIM might be present Wear gloves when it is reasonably anticipated that you will have contact with blood or OPIM Wash your hands immediately after the removal of gloves Employees exposed to human bites should wear long sleeved clothing Removing all garments that are penetrated with blood immediately. These garments are to be placed in a plastic bag. Mouth pipetting/suctioning of blood is prohibited. Always conduct procedures in a manner to minimize splashing, spraying, splattering.
What do I do
If I see a blood spill in the hall or on the playground? Do not touch. Secure the area. Contact the custodian. If I see broken glass or a needle in the trashcan? Do not touch. Secure the area. Contact the custodian. If a student in my class gets a bloody nose? Hand the student tissues, Instruct them to hold the tissues to their nose and pinch. In the case of severe injury involving blood….. Use clothing, towels, or anything else to create a barrier in order to place pressure on the wound.
One copy to employee One signed copy to school district HR Office
HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM ACCEPTANCE: I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV). This is to certify that I have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept the Hepatitis B (HBV) vaccine. DECLINATION: I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. CHECK ONE: _____ I ACCEPT Hepatitis B vaccine inoculation: OR _____ I DECLINE Hepatitis B vaccine inoculation
________________________________ Employee’s Name ________________________________ Employee’s Signature
____________________ Date
________________________________ Witness Signature
____________________ Date
VACCINE INFORMATION STATEMENT
Hepatitis B Vaccine
Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis.
Hojas de Informacián Sobre Vacunas están disponibles en Español y en muchos otros idiomas. Visite http://www.immunize.org/vis
What You Need to Know 1
What is hepatitis B?
Hepatitis B is a serious infection that affects the liver. It is caused by the hepatitis B virus. • In 2009, about 38,000 people became infected with hepatitis B. • Each year about 2,000 to 4,000 people die in the United States from cirrhosis or liver cancer caused by hepatitis B. Hepatitis B can cause: Acute (short-term) illness. This can lead to: • diarrhea and vomiting • loss of appetite • jaundice (yellow skin or eyes) • tiredness • pain in muscles, joints, and stomach Acute illness, with symptoms, is more common among adults. Children who become infected usually do not have symptoms. Chronic (long-term) infection. Some people go on to develop chronic hepatitis B infection. Most of them do not have symptoms, but the infection is still very serious, and can lead to: • liver damage (cirrhosis) • liver cancer • death
Chronic infection is more common among infants and children than among adults. People who are chronically infected can spread hepatitis B virus to others, even if they don’t look or feel sick. Up to 1.4 million people in the United States may have chronic hepatitis B infection.
Hepatitis B virus is easily spread through contact with the blood or other body fluids of an infected person. People can also be infected from contact with a contaminated object, where the virus can live for up to 7 days. • A baby whose mother is infected can be infected at birth; • Children, adolescents, and adults can become infected by: - contact with blood and body fluids through breaks in the skin such as bites, cuts, or sores; - contact with objects that have blood or body fluids on them such as toothbrushes, razors, or monitoring and treatment devices for diabetes; - having unprotected sex with an infected person;
- sharing needles when injecting drugs;
- being stuck with a used needle.
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Hepatitis B vaccine: Why get vaccinated?
Hepatitis B vaccine can prevent hepatitis B, and the serious consequences of hepatitis B infection, including liver cancer and cirrhosis. Hepatitis B vaccine may be given by itself or in the same shot with other vaccines. Routine hepatitis B vaccination was recommended for some U.S. adults and children beginning in 1982, and for all children in 1991. Since 1990, new hepatitis B infections among children and adolescents have dropped by more than 95% – and by 75% in other age groups. Vaccination gives long-term protection from hepatitis B infection, possibly lifelong.
3
Who should get hepatitis B vaccine and when?
Children and Adolescents • Babies normally get 3 doses of hepatitis B vaccine: 1st Dose: Birth 2nd Dose: 1-2 months of age 3rd Dose: 6-18 months of age Some babies might get 4 doses, for example, if a combination vaccine containing hepatitis B is used. (This is a single shot containing several vaccines.) The extra dose is not harmful. • Anyone through 18 years of age who didn’t get the vaccine when they were younger should also be vaccinated. Adults • All unvaccinated adults at risk for hepatitis B infection should be vaccinated. This includes: - sex partners of people infected with hepatitis B, - men who have sex with men, - people who inject street drugs, - people with more than one sex partner, - people with chronic liver or kidney disease, - people under 60 years of age with diabetes, - people with jobs that expose them to human blood or other body fluids,
- household contacts of people infected with hepatitis B, - residents and staff in institutions for the developmen- tally disabled, - kidney dialysis patients, - people who travel to countries where hepatitis B is common, - people with HIV infection.
• Other people may be encouraged by their doctor to get hepatitis B vaccine; for example, adults 60 and older with diabetes. Anyone else who wants to be protected from hepatitis B infection may get the vaccine.
Adults getting hepatitis B vaccine should get 3 doses — with the second dose given 4 weeks after the first and the third dose 5 months after the second. Your doctor can tell you about other dosing schedules that might be used in certain circumstances.
Who should not get hepatitis B vaccine?
• Anyone with a life-threatening allergy to yeast, or to any other component of the vaccine, should not get hepatitis B vaccine. Tell your doctor if you have any severe allergies.
What should I look for? • Any unusual condition, such as a high fever or unusual behavior. Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. What should I do? • Call a doctor, or get the person to a doctor right away. • Tell your doctor what happened, the date and time it happened, and when the vaccination was given. • Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967.
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• Anyone who is moderately or severely ill when a dose of vaccine is scheduled should probably wait until they recover before getting the vaccine.
The National Vaccine Injury Compensation Program
The National Vaccine Injury Compensation Program (VICP) was created in 1986. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling 1-800-338-2382 or visiting the VICP website at www.hrsa.gov/vaccinecompensation.
Your doctor can give you more information about these precautions. Note: You might be asked to wait 28 days before donating blood after getting hepatitis B vaccine. This is because the screening test could mistake vaccine in the bloodstream (which is not infectious) for hepatitis B infection.
8
What are the risks from hepatitis B vaccine?
Hepatitis B is a very safe vaccine. Most people do not have any problems with it. The vaccine contains non-infectious material, and cannot cause hepatitis B infection.
How can I learn more?
• Ask your doctor They can give you the vaccine package insert or suggest other sources of information. • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines
Vaccine Information Statement (Interim)
Some mild problems have been reported: • Soreness where the shot was given (up to about 1 person in 4).
What if there is a moderate or severe reaction?
VAERS does not provide medical advice.
• Anyone who has had a life-threatening allergic reaction to a previous dose of hepatitis B vaccine should not get another dose.
5
A vaccine, like any medicine, could cause a serious reaction. But the risk of a vaccine causing serious harm, or death, is extremely small. More than 100 million people in the United States have been vaccinated with hepatitis B vaccine.
6
• Pregnant women who are at risk for one of the reasons stated above should be vaccinated. Other pregnant women who want protection may be vaccinated.
4
Severe problems are extremely rare. Severe allergic reactions are believed to occur about once in 1.1 million doses.
• Temperature of 99.9°F or higher (up to about 1 person in 15).
Hepatitis B Vaccine 2/2/2012 42 U.S.C. § 300aa-26
Office Use Only
HIV/AIDS and the Workplace
What you should know about HIV, AIDS and the workplace: • HIV is the virus that causes AIDS, a disease that destroys a person’s immune system. • There are only a few ways that a person can be infected with HIV - most of which don’t involve work related situations. • It is easy to protect yourself from being infected with HIV, both in your personal life and in workplace settings. Some general information about HIV/AIDS: Acquired Immune Deficiency Syndrome (AIDS) is the final stage of an infection caused by the Human Immunodeficiency Virus (HIV). HIV attacks the body’s immune system, hurting the body’s ability to fight off diseases and other infections. There is no cure for HIV infection or AIDS. There are also no clear symptoms of HIV infection, although some people may have flu-like symptoms for a few days after they are infected with HIV. But, even if an infected person has no symptoms, feels, and looks healthy, he or she can still pass the virus to others. HIV is spread from person to person in the following body fluids: • blood • semen • vaginal secretions • breast milk HIV is NOT spread through the environment; it is a very fragile blood-borne virus. HIV-infected persons do not pose a threat to co-workers or clients during casual, day-to-day activities and contacts. You CANNOT be infected with HIV through: • handshakes
• dishes, utensils, or food
• hugs or casual touching
• sneezing or coughing
• close working conditions
• air
• telephones, office equipment, or furniture
• water
• sinks, toilets, or showers
• insects
There are only a few ways for a person to come in contact with HIV: • by having sex, either anal, oral, or vaginal, without the use of a condom; • by sharing needles, syringes, and other instruments that break the skin, such as tattoo and/or ear/body piercing needles; • from an HIV-infected mother to her baby during pregnancy, birth, or breastfeeding; and • by coming in contact with HIV-infected blood either through an open wound or through a blood transfusion. Risks from transfusions, however, are now very low because of blood-screening, which started in 1985. -OVER-
HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS
You may be wondering what HIV and AIDS could have to do with your job and workplace. Well, it depends on the type of work you do. Some people, like health care workers, have to deal with HIV and AIDS every day. Most of us, though, don’t need to give much thought to HIV or AIDS when it comes to our jobs. And that makes a lot of sense, because HIV is not spread through the type of casual day-to-day contact that most of us have with other people in our jobs. On the other hand, it does make sense to be familiar with HIV and AIDS for our own personal health, as well as with the situations that might come up at work that do involve HIV and AIDS.
HIV/AIDS and the Workplace As you can see from the information on the last page, most of the behaviors that pass HIV from one person to another do not occur in the workplace. The only way that most people in the average workplace could be exposed to HIV would be if they had an open wound and someone else’s infected blood entered their body through that broken skin. How to avoid HIV infection in the workplace: It is easy to avoid being exposed to HIV and other blood-borne diseases by using good personal hygiene and common sense at all times: • keep broken skin covered with a clean, dry bandage; • avoid direct contact with blood spills; • wear gloves to clean spills that contain visible blood; and • clean blood spills with an appropriate disinfectant or 1:10 solution of freshly mixed household bleach and water. After cleanup, wash hands thoroughly with soap and running water. Ways to reduce your risk for HIV infection in your personal life: • Do not have sex (abstain) • Delay having sex until you are in a faithful relationship with one person who you know does not have HIV. • If you choose not to abstain from sex or to limit sex to one faithful, uninfected partner, then always use a latex condom every time you have sex (oral, anal, or vaginal). If used correctly and every time you have sex, latex condoms can provide protection against HIV and other sexually transmitted diseases (STDs). • If you have a drug habit, do not share needles or syringes. If you can’t stop sharing needles/syringes, clean them with bleach and then rinse them with water between every use. Also, do not share any other type of needles, such as tattoo and ear/body piercing needles. • The best thing for your health is to stop using drugs. If you need help to stop using, call the National Drug Abuse Hotline at 1-800-662-4357. If you work with someone who has HIV and/or AIDS: If you have a cold, flu or other virus, remember that people with HIV or AIDS do not have a healthy immune system. They are more likely to become ill from a virus that a healthy person’s body could easily fight. Remember, too, that people with HIV or AIDS are just like anyone else living with a disease: they need caring, support, and understanding.
For HIV/STD testing locations in Texas, call: 2-1-1 For other HIV/STD questions, call: 1 (800) CDC-INFO (English/Español) 1 (888) 232-6348 (TTY) For more information, go to: www.dshs.state.tx.us/hivstd
DSHS TB/HIV/STD Unit DSHS Stock E4-148 Revised 10/2007
HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS
How HIV/AIDS affects you in your workplace:
Trinity Charter School 2014-2015
Payroll Understanding Your Paycheck
Salaried and Exempt from Overtime Your paycheck is processed based on your annual salary and number of days worked. You will receive the same gross amount each bi-weekly pay period. If the employee begins their employment after the start of the school year, their gross amount is prorated based on the number of days worked.
Example: Annual Salary $40,000.00yr; 26 pay periods $40,000.00/26 = $1,538.46 Bi-weekly
Non-Exempt - Eligible for Overtime Non-exempt employees will be paid at a bi-weekly rate calculated by annualizing their hourly rate and dividing it by the pay periods.
Example: Hourly Rate $12hr; 26 pay periods $12.00*1520 = $18,240yr $18,240yr/26 = $701.54 Bi-weekly
Non-exempt means that you are eligible for overtime pay; therefore you are required to submit a “Request for Overtime” form (see attached) for the actual hours worked. You will receive your bi-weekly amount plus any overtime reported. Overtime; however, MUST have prior approval. If an employee works less than the 80 hours for the bi-weekly pay, adjustments will be made. How is Overtime Calculated? Overtime is calculated for any hours actually worked over 40 in a single work week. Overtime does not include any days taken off in which you used any type of leave. Example #1: Jane worked 36 hours in the office and 5 hours on the bus for a total of 41 hours for the week. She will be paid for 1 hour of overtime. Example #2: Jane worked 30 hours in the office and 5 hours on the bus, but used 6 hours of sick leave. She will receive pay for 41 total hours, but at her regular rate of pay. Timesheet Reporting Periods Any additions, changes or deletions that need to be made to a particular staff member needs to be received by the Payroll Department the Thursday before the pay period ends. For example: Pay Period 1 is: 8/13/12 – 8/26/12. All paperwork needs to be received by NOON Thursday, 8/23/12. This date is subject to change if a holiday interrupts normal processing time. All backup paperwork, i.e., Time Corrections, Overtime and Time Off forms, to a particular pay period must be received in the Payroll Department the Monday after the pay period ends. For example: Pay Period 1 is: 8/13/12 – 8/26/12. All backup paperwork must be received by NOON Monday, 8/27/12. (see attached forms) PLEASE MAKE COPIES AND USE THE ATTACHED FORMS FOR THE 2013-2014 SCHOOL YEAR. 2|Page
When is Pay Day? Pay dates and reporting periods are determined at the beginning of each school year and based on the new school calendar (see attached Pay Date Table Main form). When and Where can Pay Checks be Picked up? Pay checks are separated by the Payroll Department at Central Office based on campus. The Payroll Department then will Fed-X each campuses checks on the Monday before the actual pay day on Tuesday. If there is a change in address, notify the Payroll Department immediately with an “Address Change“ form (see attached). Can I Get a Copy of my Pay Check(s) or W-2? Employees may get copies of their paychecks or W-2; however, please allow 10 days for processing. It is encouraged that each employee keep copies for future reference. Employees may access their patrol and employee data on TXEIS employee access at http://txeishost.net/employeeaccess/app/login
How does Direct Deposit work and Where do I Sign Up? We encourage employees to sign up for direct deposit if you haven’t done so already. This form is only required for your initial sign-up OR if you need to make changes to your current account information. Your pay will be deposited into the same account each month unless you let us know it should be changed. You cannot split your pay into separate accounts. Please complete the authorization form and submit to the Payroll Department (see attached forms). Taxes…How are They Calculated and How can I Adjust my Withholding Amounts? If you would like to check your tax withholdings or need help with questions about your personal tax status, please refer to the IRS website www.irs.gov or the Department of Revenue’s website www.dor.state.nc.us. Or contact your CPA. They can provide helpful information that the Payroll Department cannot. What is my Employee ID Number? Where Can I Find it? When Should I Use it? Each employee is assigned a unique 6-digit TCS ID number when hired. It usually starts with 000000 and then 3 digits following that. This number will be used instead of your Social Security Number. This ID number was assigned to help secure your personal information from any threat of misuse and identity theft. When filling out certain forms, you may be required to put your ID number so please remember it. If you do forget, you can contact the Payroll Department and they can tell you what your ID number is. If you have any questions, please feel free to contact the Payroll Department: Trinity Charter School Dawn Haney 8305 Crosspark Drive Austin, TX 78754 512-706-7566 3|Page
Attachments
4|Page
ADDRESS CHANGE FORM Employee Information **Form Must be Returned to the Business Office Before the End of the Pay Period in Which it Occurred**
Employee Name:
Campus:
Position:
Old Address:
New Address:
____________________________________ ____________________________________
____________________________________ ____________________________________
Effective Date: ____________________________________
Required Signature
Employee Signature:
Date:
Office Use Only
☐ Employee Folder ☐ Aetna
☐ HRB
☐ TxEIS
☐ Mid-Tex Benefits Cooperative Rev: 07/14
Time Correction Form 2014-2015 (ONE FORM PER PAY PERIOD)
**APPROVED Time Correction Form(s) must be returned to the Payroll Department the Monday after the pay period ends in which the time correction(s) occurred**
Employee Name:
Campus:
Changes: Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Reason for Missed Punch(es):
Employee Signature:
Date:
Principal/Supervisor Signature:
Date:
Rev: 7/14
Electronic Funds Transfer Authorization Form I authorize Trinity Charter School to initiate electronic funds transfer credits to my: _____Checking Account
_____Savings Account
I understand this authorization will remain in effect until I request its termination in writing. (Cancellation form on Page 2) ***PLEASE CONFIRM THE ACH ROUTING NUMBER AND ACCOUNT NUMBER WITH YOUR BANKING INSTITUTION FOR PROPER PROCESSING OF YOUR FUNDS*** Bank Name:
_________________________________________________________________
Branch:
_________________________________________________________________
Bank Phone #:_________________________________________________________________ City:
____________________________
State: ___________ Zip:
_________________
Bank Transit Number: ____________________________ (Attach copy of VOIDED check or savings deposit slip)
Bank Account Number:
____________________________
Employee Name (Printed):
_____________________________________________________
Employee Signature: _________________________________________ Date: ___________ Employee ID Number:_______________________ Campus:
_______________________
Instructions for Direct Deposit: 1. Please verify checking/savings account number; 2. Make sure you sign and list your Employee ID Number on the form; and 3. Attach a VOIDED check for Checking or a VOIDED Deposit Slip for Savings.
Direct deposit should begin one month after you have returned this form. Direct deposits will be for the entire check amount – no partials please.
5/2012
Electronic Funds Transfer Cancellation Form Please cancel my electronic funds transfer credits to my:
_____Checking Account
_____Savings Account
Employee Name:
_________________________________________
Employee ID #:
_________________________________________
Campus:
_________________________________________
Effective Date:
_________________________________________
_________________________________ Employee Signature
____________________________ Date
5/2012
Time Correction Form 2014-2015 (ONE FORM PER PAY PERIOD)
**APPROVED Time Correction Form(s) must be returned to the Payroll Department the Monday after the pay period ends in which the time correction(s) occurred**
Employee Name:
Campus:
Changes: Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Reason for Missed Punch(es):
Employee Signature:
Date:
Principal/Supervisor Signature:
Date:
Rev: 7/14
2014‐2015 Campus Employee Work Calendar FEBRUARY 2015
AUGUST 2014 S M T W T F S 1 3
4
5
6
7
LEGEND
2
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Student/Staff Holiday (unless it is a specified In‐Service day)
First/Last day of classes
(Unless more than 2 make‐up days required)
1
2
3
SEPTEMBER 2014 1
2
3
4
5
6
8
9
10 11 12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Work Schedule 190 195 206 210 220
8
9
10 11 12 13 14
5
6
7
3
4
Start
End
8/18/2014 8/11/2014 8/11/2014 8/11/2014 8/11/2014
6/9/2015 6/9/2015 6/24/2015 6/30/2015 7/15/2015
S M T W T F S 1
2
3
8
9
10 11 12 13 14
8
9
10 11
4
5
6
7
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
APRIL 2015 S M T W T F S 5
Paydate
7
MARCH 2015
Bad Weather Make‐Up Day
S M T W T F S 2
6
22 23 24 25 26 27 28
OCTOBER 2014 1
5
Full Day All Staff In‐service
*School in session only if needed
S M T W T F S
4
15 16 17 18 19 20 21
(7:30 a.m. ‐ 3:30 pm)
31
7
S M T W T F S
Pay Period Start
Pay Period End
6
7
1
2
3
4
8
9
10 11
12 13 14 15 16 17 18 19 20 21 22 23 24 25
12 13 14 15 16 17 18
======
======
======
19 20 21 22 23 24 25
9/2/2014
8/11/2014
8/24/2014
26 27 28 29 30 31
9/16/2014
8/25/2014
9/7/2014
MAY 2015
9/30/2014
9/8/2014
9/21/2014
S M T W T F S
10/14/2014
9/22/2014
10/5/2014
NOVEMBER 2014
26 27 28 29 30
1
2
8
9
S M T W T F S
10/28/2014
10/6/2014
10/19/2014
3
1
11/11/2014
10/20/2014
11/2/2014
10 11 12 13 14 15 16
4
5
6
7
4
5
6
7
2
3
8
11/25/2014
11/3/2014
11/16/2014
17 18 19 20 21 22 23
9
10 11 12 13 14 15
11/17/2014 12/1/2014 12/15/2014
11/30/2014 12/14/2014 12/28/2014
31
23 24 25 26 27 28 29
12/9/2014 12/23/2014 1/6/2015
30
1/20/2015
12/29/2014
1/11/2015
JUNE 2015
2/3/2015
1/12/2015
1/25/2015
S M T W T F S
DECEMBER 2014
2/17/2015
1/26/2015
2/8/2015
S M T W T F S
3/3/2015
2/9/2015
2/22/2015
7 8 9 10+ 11+ 12 13 14 15 16 17 18 19 20
16 17 18 19 20 21 22
24 25 26 27 28 29 30
1
2
3
4
5
6
1
2
3
6
3/17/2015
2/23/2015
3/8/2015
8
9
10 11 12 13
3/31/2015
3/9/2015
3/22/2015
21 22 23 24 25 26 27
14 15 16 17 18 19 20
4/14/2015
3/23/2015
4/5/2015
28 29 30
21 22 23 24 25 26 27
4/28/2015
4/6/2015
4/19/2015
28 29 30 31
5/12/2015
4/20/2015
5/3/2015
JULY 2015
5/26/2015
5/4/2015
5/17/2015
S M T W T F S
JANUARY 2015
6/9/2015
5/18/2015
5/31/2015
S M T W T F S
6/23/2015
6/1/2015
6/14/2015
5
7
4
5
6
7
1
2
3
8
9
10 11
4
1
2
3
7/7/2015
6/15/2015
6/28/2015
12 13 14 15 16 17 18
8
9
10
6/29/2015 7/13/2015
7/12/2015 7/26/2015
19 20 21 22 23 24 25
11 12 13 14 15 16 17
7/21/2015 8/4/2015
18 19 20 21 22 23 24
8/18/2015
7/27/2015
8/9/2015
4
5
6
7
25 26 27 28 29 30 31 09/30/14 & 3/31/15 = No h/c taken out
26 27 28 29 30 31
Electronic Funds Transfer Authorization Form I authorize Trinity Charter School to initiate electronic funds transfer credits to my: _____Checking Account
_____Savings Account
I understand this authorization will remain in effect until I request its termination in writing. (Cancellation form on Page 2) ***PLEASE CONFIRM THE ACH ROUTING NUMBER AND ACCOUNT NUMBER WITH YOUR BANKING INSTITUTION FOR PROPER PROCESSING OF YOUR FUNDS*** Bank Name:
_________________________________________________________________
Branch:
_________________________________________________________________
Bank Phone #:_________________________________________________________________ City:
____________________________
State: ___________ Zip:
_________________
Bank Transit Number: ____________________________ (Attach copy of VOIDED check or savings deposit slip)
Bank Account Number:
____________________________
Employee Name (Printed):
_____________________________________________________
Employee Signature: _________________________________________ Date: ___________ Employee ID Number:_______________________ Campus:
_______________________
Instructions for Direct Deposit: 1. Please verify checking/savings account number; 2. Make sure you sign and list your Employee ID Number on the form; and 3. Attach a VOIDED check for Checking or a VOIDED Deposit Slip for Savings.
Direct deposit should begin one month after you have returned this form. Direct deposits will be for the entire check amount – no partials please.
5/2012
Electronic Funds Transfer Cancellation Form Please cancel my electronic funds transfer credits to my:
_____Checking Account
_____Savings Account
Employee Name:
_________________________________________
Employee ID #:
_________________________________________
Campus:
_________________________________________
Effective Date:
_________________________________________
_________________________________ Employee Signature
____________________________ Date
5/2012
Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name
Employee ID#
Employer Name
Employer ID#
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected. Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.” Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension. For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.” For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office. I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security benefits.
Signature of Employee
Form SSA-1945 (12-2004)
Date
Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled. Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse or an ex-spouse. Employers must: • Give the statement to the employee prior to the start of employment; • Get the employee’s signature on the form; and • Submit a copy of the signed form to the pension paying agency. Social Security will not be setting any additional guidelines for the use of this form. Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945. Paper copies can be requested by email at
[email protected] or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.
Form SSA-1945 (12-2004)
2014-2015 Payroll Information Sheet Name: _________________________________
Campus: ______________
Position: Pay Rate:
hourly/ daily
I have chosen the following pay schedule:
10 month schedule; 22 payments (only applicable to nonexempt working 190 or 195 per school year) 10 month schedule; 23 payments (only applicable to nonexempt working 206 per school year)
12 month schedule; 26 payments
I understand and agree that my employer, Trinity Charter School, will be annualizing my pay.
Employee Signature
Date
(Please Note: Schedule changes can only be made as a new hire or at the beginning of the school year.) 6/12
TCS Amendment to Non-Subscription, Employee Injury Plan By signing this, I acknowledge that I have received the information regarding the amendments to the employee injury plan that will go into effect on 8/15/12. I also understand that all information regarding the employee injury plan for TCS, to include the plan document, summary plan, new hire and arbitration information can be found on the LSS intranet under Risk Management or requested from my facility HR contact.
________________________________________ Name
________________________________________ Signature
________________________________________ Date
Staff Emergency Contact Form For 2014-2015 School Year
Employee Name: Employee ID #:
Emergency Contact Information: Contact Name: Relationship: Phone Number: Address:
Emergency Contact Information: Contact Name: Relationship: Phone Number: Address:
EMPLOYEE CERTIFICATION OF AUTOMOBILE INSURANCE COVERAGE Trinity Charter School requires that all employees using personally owned and company owned automobiles for agency business have the minimum automobile insurance required by the state in which they will be driving. Please complete the form below and return to the facility business office. THIS IS TO CERTIFY THAT I, ______________________________________________ (PRINT NAME) Check One ( )
Have the automobile coverage outlined above.
( )
Do not have the coverage outlined above and will not drive any personally owned or company owned automobile on agency business.
________________________________ Employee Signature _____________________________ Date 09/10
8/14
New Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 (expires 1-31-201)
PART A: General Information ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ:͑ΥΙΖ͑ΖΒΝΥΙ͑ ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ ͑
What is the Health Insurance Marketplace? ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡
Can I Save Money on my Health Insurance Premiums in the Marketplace? ΊΠΦ͑ΞΒΪ͑ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑ ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑ ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑ ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑͟͢ ͑ ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑ ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑ ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞ ΥΒΩ͑ΓΒΤΚΤ͑͟
͑ How Can I Get More Information? ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑ Dawn Haney - Office Manager at
[email protected] or 512-706-7566 ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟ Amy Freeman, Human Resources 512-706-7564 ͑ ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟ΝΖΒΤΖ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟
͑͢ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͑ ͓ΞΚΟΚΞΦΞ͑ ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟
PART B: Information About Health Coverage Offered by Your Employer ΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑ ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑ ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟ 3. Employer name
4. Employer Identification Number (EIN)
Casa Gracia DBA Trinity Charter School
742314606
5. Employer address
6. Employer phone number
8305 Cross Cross Park Park Dr Drive 8605
512-706-7564 512-706-7566
7. City
Austin
8. State
9. ZIP code
TX
78754
10. Who can we contact about employee health coverage at this job?
DawnFreeman, Haney Human Resources Amy 11. Phone number (if different from above)
͑
12. Email address
[email protected] [email protected]
ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑ x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑
ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑ ͑ ͑ ͑ ͑ ͑ ✔
΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑ ͑ ͑ Actively employed and making monthly contributions to TRS or regularly scheduled to work 10 or more ͑ hours per week. ͑ ͑ x ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑ ✔
ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑ ͑ Spouse (including common law spouse); Natural/adopted child, step-child, foster child, legal guardianship ͑ (under the age of 26); Other child (Under the age of 26 and unmarried); Grandchildren (under the age of 26)* ͑ *Must meet eligibility criteria specified in the eligible dependents section of the benefits handbook. ͑
ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ ͑
ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑ ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟ ͑ ͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝ ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑ ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑ ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ ͑ ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟ΖΣΖ͘Τ͑ΥΙΖ͑ ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟ ͑
΅ΙΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΓΖΝΠΨ͑ΔΠΣΣΖΤΡΠΟΕΤ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ͶΞΡΝΠΪΖΣ͑ʹΠΧΖΣΒΘΖ͑΅ΠΠΝ͑͑͟ʹΠΞΡΝΖΥΚΟΘ͑ΥΙΚΤ͑ΤΖΔΥΚΠΟ͑ΚΤ͑ΠΡΥΚΠΟΒΝ͑ΗΠΣ͑ ΖΞΡΝΠΪΖΣΤ͑͝ΓΦΥ͑ΨΚΝΝ͑ΙΖΝΡ͑ΖΟΤΦΣΖ͑ΖΞΡΝΠΪΖΖΤ͑ΦΟΕΖΣΤΥΒΟΕ͑ΥΙΖΚΣ͑ΔΠΧΖΣΒΘΖ͑ΔΙΠΚΔΖΤ͑͟ ͑ 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee)
͑ 14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly ͺΗ͑ΥΙΖ͑ΡΝΒΟ͑ΪΖΒΣ͑ΨΚΝΝ͑ΖΟΕ͑ΤΠΠΟ͑ΒΟΕ͑ΪΠΦ͑ΜΟΠΨ͑ΥΙΒΥ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΡΝΒΟΤ͑ΠΗΗΖΣΖΕ͑ΨΚΝΝ͑ΔΙΒΟΘΖ͑͝ΘΠ͑ΥΠ͑ΦΖΤΥΚΠΟ͑ͧ͑͢͟ͺΗ͑ΪΠΦ͑ΕΠΟ͘Υ͑ ΜΟΠΨ͑͝΄΅͑ΒΟΕ͑ΣΖΥΦΣΟ͑ΗΠΣΞ͑ΥΠ͑ΖΞΡΝΠΪΖΖ͑͟ ͑ 16. What change will the employer make for the new plan year?
Employer won't offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
Ͳ͑חΟ͑ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ΚΗ͑ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ΟΠ͑ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ΤΦΔΙ͑ΔΠΤΥΤ͙͑΄ΖΔΥΚΠΟ͑ͤͧͳ͙Δ͚͙͚͙ͣʹ͚͙ΚΚ͚͑ΠΗ͑ΥΙΖ͑ͺΟΥΖΣΟΒΝ͑ΖΧΖΟΦΖ͑ʹΠΕΖ͑ΠΗ͚͑ͪͩͧ͑͢
NEW HEALTH INSURANCE MARKETPLACE COVERAGE OPTIONS AND YOUR HEALTH COVERAGE
RECEIPT OF ACKNOWLEDGMENT
By my signature below, I acknowledge that I have received a copy of the New Health Insurance Marketplace Coverage Notice. I also understand that it is my responsibility for further inquiry of eligibility and coverage requirements for health insurance coverage through the Marketplace, which begins in October 2013.
___________________________________ Employee Signature
Date
___________________________________ Print Employee Name
Employee Work Location
SECURITY RELEASE FORM The following items have been issued to
Employee Name:
Employee ID: Campus/Location: Position: *Upon termination of employment all items must be returned before issuance of the final pay check*
ASSET
ASSET I.D. (If applicable)
DATE ISSUED
BADGE Desk #: File cabinet #: Keys ‐ Room #:
DATE RETURNED
Cost to replace items not returned OTHER ITEMS: (i.e., uniforms, calling card, equipment, etc. Radio/headset: Amy Freeman, Human Resources$ at 512-706-7564 Computer: Amy Freeman, Human Resources $ $ Desktop Laptop Tablet $ Phone: $ Monitor: $ Printer/Scanner: $
I verify that I have received the items listed above. I understand that I will be responsible for reimbursing the agency for the costs of these items if they are not returned upon termination of employment.
I verify that the items listed above have been returned.
Employee’s Signature Date
Employee’s Signature Date
Supervisor’s Signature Date
Supervisor’s Signature Date
Revised 7/14
1
2014-2015 Health Plans
Enrollment Guide
Table of Contents
Welcome.........................................................................................................................................................1 Choosing a plan option....................................................................................................................................1 What's new...............................................................................................................................................1 Medical Benefits • Benefits Summaries and Plan Comparisons............................................................................................3 • Prescription Drugs.................................................................................................................................7 • How the Medical Plans Work..................................................................................................................9 • Tips to Make Your Medical Plan Work for You...........................................................................................10 • Wellness Resources...............................................................................................................................11 HMO Benefits • Benefits Summaries and Plan Comparisons............................................................................................13 • HMO Plan Service Areas........................................................................................................................15 • Wellness Resources...............................................................................................................................16 Cost for Coverage ..........................................................................................................................................17 Enrollment • Who can enroll......................................................................................................................................18 • How to enroll.........................................................................................................................................19 • Making changes/special enrollment events.............................................................................................20 Important Notices • Initial notice..........................................................................................................................................21 • Medicare Beneficiaries and Medicare Part D...........................................................................................22 • Notice of Privacy Practices.....................................................................................................................22
Questions? Call Customer Service
®
ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 1-800-222-9205 –TRS-ActiveCare Customer Service 8 a.m.-6 p.m. CT (Mon-Fri) 1-800-628-3323 – TYY number
1-800-321-7947, 24 hours a day (Mon-Sun)
1-800-884-4901, 8 a.m.-6 p.m. CT (Mon-Fri)
1-855-463-7264, 8 a.m.-5 p.m. CT (Mon-Fri)
This guide provides an overview of the TRS-ActiveCare program benefits. For a detailed description of your program, see your TRS-ActiveCare Benefits Booklet or your HMO’s Evidence of Coverage. The Benefits Booklet will be available online before September 1, 2014 and is the official TRS-ActiveCare statement on benefits. HMO Evidence of Coverage documents will be available online and printed copies may be available from your HMO. TRS-ActiveCare benefits will be paid according to the Benefits Booklet or your HMO’s Evidence of Coverage and other legal documents governing the program. This Enrollment Guide applies to the 2014-2015 TRS-ActiveCare plan year and supersedes any prior version of the Enrollment Guide. However, each version of the Enrollment Guide remains in effect for the plan year for which it applies. In addition to TRS laws and regulations, the Enrollment Guide is TRS-ActiveCare’s official statement about enrollment matters contained in the Enrollment Guide and supersedes any other statement or representation made concerning TRS-ActiveCare enrollment, regardless of the source of that statement or representation. TRSActiveCare reserves the right to amend the Enrollment Guide at any time. TRS does not offer, nor does it endorse, any form of supplemental coverage for any of the health coverage plans available under TRS-ActiveCare. To obtain information about any coverage that is purported to be a companion or supplement to any TRS-ActiveCare plan, individuals should contact the organization making such offerings and/or the Texas Department of Insurance (TDI) at http://www.tdi.state.tx.us or the TDI Consumer Helpline at 1-800-252-3439. Medical benefits for TRS-ActiveCare are administered by Aetna. Prescription drug benefits for ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 are administered by Caremark. HMO plans are provided by: SHA, L.L.C. dba FirstCare Health Plans, Scott and White Health Plan, and Allegian Insurance Company dba Allegian Health Plans, formerly Valley Baptist Insurance Company dba Valley Baptist Health Plans.
3
Welcome
Enrollment Period: July 21–August 31
Choosing a plan option Welcome to 2014-2015 Plan Enrollment
ActiveCare 3 to be discontinued
Enroll now! During the plan enrollment period, you may select a plan option, make plan changes and add or delete dependents from your health coverage without a special enrollment event.
Effective September 1, 2014, ActiveCare 3 will be discontinued as a plan option. If you are currently enrolled in ActiveCare 3, you will be automatically enrolled in ActiveCare 2 unless you make a different plan selection by September 1, 2014.
This guide provides an overview of what is new for the 2014-2015 plan year, descriptions of the available plan options, a list of important reminders and actions required for enrollment and participation in the TRS-ActiveCare health plans, as well as certain notifications about your health benefits. Additional information about your options for coverage is available to you online at www.trs.state.tx.us/trsactivecare or you can call TRS-ActiveCare Customer Service at 1-800-222-9205 and speak to an Aetna Health Concierge.
New plan – ActiveCare Select ActiveCare Select is a new plan option under TRS-ActiveCare that is designed to meet the essential health benefits required of all health plans, while limiting less frequently used benefits and services. Be sure to check out this new plan’s benefits and limitations in the Benefits Summaries and Plan Comparisons section of this Enrollment Guide.
New ID cards for plan members
You should choose your plan carefully. You may not change plans during a plan year unless you experience a qualified special enrollment event. There may be restrictions to making plan changes in future plan years as well.
Aetna If you enroll in one of the TRS-ActiveCare plan options (i.e., not an HMO), you will receive a new Aetna member ID card in the mail. You will receive the new card even if you are staying in the same TRS-ActiveCare plan option, because your plan will now be administered by Aetna.
What's new
The cards are family ID cards – which means up to five covered family members will be listed on the card. If you have more than four dependents, you will receive an additional card displaying your other dependents. If you need more ID cards, call TRS-ActiveCare Customer Service at 1-800-222-9205 and speak to an Aetna Health Concierge. You also may request additional cards (or replacements for lost cards) by logging in to your secure member website, Aetna Navigator ® at www.trsactivecareaetna.com. You will need to be registered with Aetna Navigator to use its features and tools. Turn to page 12 to learn more.
Aetna and Caremark will be the new plan administrators Effective September 1, 2014, Aetna will replace Blue Cross and Blue Shield ® of Texas as the administrator of the ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans. Caremark will replace Express Scripts® as the administrator of our prescription drug benefits. About Aetna Aetna is one of America’s most experienced and progressive health insurance companies. Choosing Aetna to administer TRS-ActiveCare plans means you and your family can enjoy the advantages of:
Caremark Your prescription benefit plan is designed to bring you quality pharmacy care that will help you save money. If you enroll in one of the TRS-ActiveCare plan options, you will receive a new Caremark prescription drug ID card in the mail. You will receive the new card even if you are staying in the same TRS-ActiveCare plan option. Included with the ID card will be Caremark Welcome Kit reflecting your elected prescription benefit plan. If you need to obtain a temporary ID card or order additional cards, you can call 1-800-222-9205 and select option #2 to speak to a Caremark representative, or you can go online at www.caremark.com/trsactivecare.
• One of America’s largest provider networks • One-on-one support from nurse consultants and other health professionals to help you reach your wellness goals • A Health Concierge available by phone for answers and guidance on care and benefits • Online services and mobile apps for easy access to health information and tools for those who travel
Be sure to take your prescription ID card to your pharmacy when you get a prescription filled for the first time. Your TRS-ActiveCare member number is the same on both your Aetna medical card and your Caremark prescription benefit card, so you may present either card to your pharmacy when you fill a prescription for medications.
• Enhanced customer service that helps you better understand and use Aetna benefits, programs and tools, and much more To get the best view of Aetna resources available to you, visit www.trsactivecareaetna.com for plan and benefit information. About Caremark Caremark is the largest pharmacy health care provider in the United States. Caremark’s network includes more than 64,000 pharmacies nationwide, including chain pharmacies and 20,000 independent pharmacies.
ID card distribution If you change your plan election after August 11, 2014, you will receive a second set of ID cards in the mail from Aetna and Caremark. The new cards will reflect your updated plan information. Please destroy all old ID cards when you receive your replacement cards. Please note: If prior to receiving your second set of Caremark ID cards, you need to fill a prescription beginning September 1, you can use your original Caremark card.
Through Caremark pharmacy services, you can order maintenance and specialty medications online or by phone, and have them delivered directly to you. The Caremark website offers these and other services, including Ask-a-Pharmacist, for answers and information about your medications. To start using these and other features and services, register at www.caremark.com/trsactivecare.
1
What's New
Aetna Health Concierge: For help with your medical benefits questions and health care needs
New Ways to Save
The Aetna Health Concierge is your single point of contact for medical benefits and wellness information. Your Aetna Health Concierge is a medical benefits expert who can help you put all the pieces together – benefits, providers, services, programs and tools – to make informed decisions, get the care and services you need, save money and live healthier. Your Aetna Health Concierge can confirm if your doctor is currently in the network, help you find the right doctor for your condition or problem, and even help you make an appointment.
As a TRS-ActiveCare participant you get plenty of extras that help save you money such as free or discounted: • Lab services at Quest Diagnostics®. For more details, see page 5. • Doctor visits through Teladoc®. To learn more about this program, see page 11.
Call when you have a problem or question. Get help to find the right specialist. Understand how a medical claim was paid. Know about programs that can help with specific health conditions and needs. Get a guided tour of Aetna Navigator features and see how they can work for you. Whether you need a quick answer, help to untangle a difficult issue or someone to explain your benefits, you have an advocate dedicated to your needs. Call TRS-ActiveCare Customer Service at 1-800-222-9205 and speak to an Aetna Health Concierge.
Welcome to your Aetna administered plan The TRS-ActiveCare plans being offered for the 2014-2015 plan year will be administered by Aetna, a trusted administration support that has served TRS retirees since 1986. The TRS-ActiveCare 1-HD and ActiveCare 2 plans are Aetna Choice POS II plans, which work very much like the PPO plans you are familiar with. You are free to receive care from any licensed doctor or other health care provider. When you choose providers who belong to Aetna’s network, you will pay less out of your own pocket for covered services. The ActiveCare Select plan is a network-only plan similar to an HMO. You must see network providers for the plan to cover and help pay for care.
ActiveCare tools With the 2014-2015 plan year comes new tools to help you choose wisely and save money: • Aetna Navigator – A website where you can check the status of claims, view benefit information, find a doctor and much more. • Member Payment Estimator – This tool lets you find and compare actual costs for common procedures and treatments before you receive care.
When you receive your new member ID card, you will see “Choice POS II” for ActiveCare 1-HD and ActiveCare 2 or “Aetna Select Open Access” for ActiveCare Select (along with the Accountable Care Network, if applicable) printed on the front. This identifies the plan you are enrolled in, as well as the provider network associated with it. To find providers in the network, go to www.trsactivecareaetna.com and click “Find a doctor or facility” on the right side of the home page.
• Personal Health Record – This resource shows the care you have received based on claim data–such as medical procedures, services received, preventive care provided. • Mobile Apps – They keep you connected. iTriage ® helps you make sense of your health care options, check a symptom, find the right doctor, even look up ER wait times.
We invite you to learn about your Aetna medical plan and take advantage of all it offers for your health and well-being.
• Self-Service WellSystems Enrollment Portal – You will be able to enroll, change your address, review your dependents and plan election. May not apply to district/entity with Third Party Administrators.
Uniform Summary of Benefits and Coverage The uniform Summary of Benefits and Coverage (SBC) provision of the Patient Protection and Affordable Care Act requires all insurers and group health plans to provide consumers with a SBC to describe key plan features in a mandated format, including limitations and exclusions. This provision also requires that consumers have access to a uniform glossary of terms commonly used in health care coverage. For TRS-ActiveCare, these provisions became effective April 22, 2013, and SBCs will be available online as shown below. You can view the glossary at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf. To review a Summary of Benefits and Coverage, visit the website or call the number below to request a copy ActiveCare 1-HD, ActiveCare Select, ActiveCare 2 Plans
www.trsactivecareaetna.com
1-800-222-9205
FirstCare Health Plans
www.firstcare.com/trs
1-800-884-4901
Scott & White Health Plan
www.trs.swhp.org
1-800-321-7947
Allegian
www.allegianhealthplans.com
1-855-463-7264
2
ActiveCare Medical Benefits Summaries and Plan Comparisons
Type of Service
ActiveCare 1-HD Network
ActiveCare Medical Benefits Summaries and Plan Comparisons
ActiveCare Select Network
ActiveCare 2 Network
Non-Network
Deductible (per plan year)
$2,500 employee only $5,000 employee and spouse; employee and child(ren); employee and family
$1,200 individual $3,600 family
$1,000 individual $3,000 family
AC1-HD & AC2: Deductibles same as network AC Select: No coverage for non-network services
Out-of-Pocket Maximum (per plan year; includes medical deductibles/copays/ coinsurance)
$6,350 employee only* $9,200 employee and spouse; employee and child(ren); employee and family*
$6,350 individual $9,200 family
$6,000 per individual $12,000 family
AC1-HD & AC2: Out-of-pocket maximums same as network AC Select: No coverage for non-network services
Doctor Office Visits
20% after deductible
$30 copay for primary $60 copay for specialist
$30 copay for primary $50 copay for specialist
AC1-HD & AC2: 40% after deductible AC Select: Not covered
Preventive Care
Plan pays 100% (deductible waived)
Plan pays 100% (deductible waived)
Plan pays 100% (deductible waived)
AC1-HD & AC2: 40% after deductible AC Select: Not covered
Teladoc Physician Services
$40 consultation fee (applies to deductible and out-of-pocket maximum)
Plan pays 100% (deductible waived)
Plan pays 100% (deductible waived)
AC1-HD, AC Select, AC 2: Not applicable
Diagnostic Lab
20% after deductible
Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility
Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility
AC1-HD & AC2: 40% after deductible AC Select: Not covered
High-Tech Radiology (CT scan, MRI, nuclear medicine)
20% after deductible
$100 copay per service plus 20% after deductible
$100 copay per service plus 20% after deductible
AC1-HD: 40% after deductible AC Select: Not covered AC2: $100 copay per service plus 40% after deductible
Inpatient Hospital (facility charges)
20% after deductible (preauthorization required)
$150 copay per day plus 20% after deductible ($750 maximum copay per admission; preauthorization required)
$150 copay per day plus 20% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required)
AC1-HD: 40% after deductible AC Select: Not covered AC2: $150 copay per day plus 40% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required)
Inpatient Hospital (physician/surgeon fees)
20% after deductible
20% after deductible
20% after deductible
AC1-HD & AC2: 40% after deductible AC Select: Not covered
Outpatient Surgery
20% after deductible
$150 copay per visit plus 20% after deductible
$150 copay per visit plus 20% after deductible
AC1-HD: 40% after deductible AC Select: Not covered AC2: $150 copay per visit plus 40% after deductible
Bariatric Surgery (physician charges; only covered if performed at an IOQ facility)
$5,000 copay plus 20% after deductible
Not covered
$5,000 copay (does not apply to out-of-pocket maximum) plus 20% after deductible
AC1-HD, AC Select, AC2: Not covered
Ambulance
20% after deductible
20% after deductible
20% after deductible
AC1-HD & AC2: 20% after deductible AC Select: Not covered
Emergency Room (true emergency use)
20% after deductible
$150 copay plus 20% after deductible (copay waived if admitted)
$150 copay plus 20% after deductible (copay waived if admitted)
AC1-HD & AC2: Same as network AC Select: Same as network
Urgent Care
20% after deductible
$50 copay per visit plus 20% after deductible
$50 copay per visit plus 20% after deductible
AC1-HD & AC2: 40% after deductible AC Select: Not covered
Maternity Care (physician charges; does not include laboratory tests; hospital/facility charges are covered same as inpatient hospital facility charges)
Initial Visit to Confirm Pregnancy 20% after deductible
Initial Visit to Confirm Pregnancy $30 copay
Initial Visit to Confirm Pregnancy $30 copay
Prenatal Care/Delivery/Postnatal Care AC1-HD & AC2: 40% after deductible AC Select: Not covered
Routine Prenatal Care Plan pays 100% (deductible waived)
Routine Prenatal Care Plan pays 100% (deductible waived)
Routine Prenatal Care Plan pays 100% (deductible waived)
Delivery/Postnatal Care 20% after deductible
Delivery/Postnatal Care 20% after deductible
Delivery/Postnatal Care 20% after deductible
Outpatient Services 20% after deductible
Outpatient Services $60 copay
Outpatient Services $50 copay
Outpatient Services AC1-HD & AC2: 40% after deductible AC Select: Not covered
Inpatient Services 20% after deductible (preauthorization required)
Inpatient Services $150 copay per day plus 20% after deductible ($750 maximum copay per admission; preauthorization required)
Inpatient Services $150 copay per day plus 20% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required)
Inpatient Services AC1-HD: 40% after deductible AC Select: Not covered AC2: $150 copay per day plus 40% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required)
Mental Health/Behavioral Health/ Substance Abuse Disorders
*Includes prescription drug coinsurance
3
4
ActiveCare Medical Benefits Summaries and Plan Comparisons
ActiveCare 1-HD and Health Savings Accounts
met by one family member or a combination of family members; however, there are no benefits until covered expenses equaling the deductible amount ($5,000) have been incurred.
ActiveCare 1-HD meets the current IRS definition of a high deductible health plan (HDHP) for all tiers of coverage (employee only, employee and spouse, employee and child(ren), and employee and family), and offers plan participants the opportunity to contribute pretax dollars into a health savings account (HSA). An HSA allows individuals to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.
For ActiveCare Select and ActiveCare 2 the deductible applies to each covered person individually, up to the maximum per family. For example, under ActiveCare 2, which has a $1,000 individual and $3,000 family deductible, if your daughter incurs $1,000 in medical bills, her deductible is met and the plan will pay any subsequent medical bills for your daughter for the year even though the family deductible of $3,000 has not been met yet.
To be eligible for an HSA, an individual must be covered by an HDHP, must not be covered by other health insurance (does not apply to specific injury insurance and accident, disability, dental care, vision care, long-term care), is not eligible for Medicare and cannot be claimed as a dependent on someone else’s tax return.
Added Savings and Value with Quest Diagnostics®
TRS does not offer HSAs, but some entities participating in TRS-ActiveCare do provide this option to their employees. Individuals should contact their Benefits Administrator to determine whether an HSA is available through their employer. Individuals can also establish an HSA by working directly with financial institutions offering this product. Many banks and credit unions offer custodial account services for individuals wishing to establish an HSA. TRS does not have a list of these institutions and does not endorse any particular HSA product. Please contact financial institutions serving your area to obtain further information.
You can take advantage of extra savings when you need a lab test. Quest Diagnostics® has agreed to lower rates for TRS-ActiveCare participants. That helps you save on out-of-pocket costs. In fact, the ActiveCare 2 and ActiveCare Select plans cover lab services at 100% if you use a Quest Diagnostics facility. In addition to savings, Quest Diagnostics also gives you access to:
• Thousands of locations near where you live and work • Appointment scheduling online or by phone • Email reminders to help you keep track of your appointments • Saturday hours as well as extended hours at many locations • Free courier service to pick up lab work from most doctor's offices
Family deductibles and the differences between plans A deductible is the amount of out-of-pocket expense that must be paid for health care services by the plan participant before becoming payable by the health plan. For ActiveCare 1-HD, before the plan pays for any of your family’s covered medical expenses, the entire amount of the deductible must be met first. It can be
5
ActiveCare Medical Benefits Summaries and Plan Comparisons
New TRS-ActiveCare Select plan
Aetna Whole Health Better health, better care, better cost
ActiveCare Select is a new health plan option available for the 2014-2015 plan year. With ActiveCare Select, you are free to see any network provider without a referral. However, there is no coverage if you see a provider who is not in the plan network. The only exception is for a true medical emergency.
This is what Aetna Whole Health is all about. It is a participant-centered approach that may differ from care you have had in the past. Here are some of the ways it is different. The members of your care team:
There are two networks that make up the ActiveCare Select plan, the Aetna Select (Open Access) network or the Aetna Whole HealthSM network.
• Strive to keep you healthy or improve your health, not just treat you when you are sick or injured
Aetna Whole Health is an Accountable Care Network. With Aetna Whole Health, you have a health care team of doctors, nurses, therapists and other providers whose goal is to work with you to meet your unique needs and keep you healthy.
• Can better coordinate your care because they can see how other doctors are treating you, what medicines you are taking, your lab results, your health history and more
If you live in or around San Antonio, Dallas, Austin, or Houston (in one of the counties listed below) and elect ActiveCare Select as your 2014-2015 plan option, you will be required to use providers who belong to the Aetna Whole Health network. If you do not live in one of the counties listed, you must choose providers in the Aetna Select (Open Access) network.
• Are up to date on medical guidelines and clinical information so they can spot problems early and develop personalized care plans for you • Encourage you to play an active and informed role in your health and health care decisions
Locating an ActiveCare Select provider To find an ActiveCare Select provider go to www.trsactivecareaetna.com and click “Find a doctor or facility, then DocFind.” You will then be able to search by provider name, specialty, procedure or condition.
Note: For ActiveCare 1-HD and ActiveCare 2, non-network providers may bill you for amounts exceeding the allowable amount. The non-network provider is not required to accept the allowable amount as payment in full and may balance bill you for the difference between the allowable amount and the non-network provider’s billed charge. You will be responsible for this balance bill amount, which may be considerable. Remember, there is no coverage for non-network providers for ActiveCare Select plan, except for true emergency care.
Important Note: When searching for providers in the ActiveCare Select plan, you must choose from a network based on where you live.
If you live in one of these counties…
Choose “TRS-ActiveCare Select/ Aetna Whole Health” in the “Select a Plan” box and then pick:
• Bexar • Comal • Guadalupe • Kendall
Baptist Health System and HealthTexas Medical Group
• Collin • Dallas • Denton • Ellis • Parker • Rockwall • Tarrant
Baylor Scott & White Quality Alliance
• Ft. Bend • Harris • Montgomery
Memorial Hermann Accountable Care Network
• Hays • Travis • Williamson
Seton Health Alliance
If you live in a county (not listed above)
Therefore, under the ActiveCare Select plan, you will be responsible for all billed charges from a non-network provider.
Please note: If you enroll in the ActiveCare Select plan (Aetna Whole Health) network and move out of the Aetna Whole Health network area during the 2014-2015 plan year, you will remain in the ActiveCare Select plan and may choose providers in the ActiveCare Select (Open Access) network. You will receive a new ID card indicating the network change.
Note: A “specialist” is any physician other than a family practitioner, internist, OB/GYN or pediatrician.
Note: This is a general summary of your options under the TRS-ActiveCare program. Please refer to your Benefits Booklet for details specific to your plan. You can also view a Summary of Benefits and Coverage at www.trsactivecareaetna.com or call TRS-ActiveCare Customer Service at 1-800-222-9205 to request a copy.
Choose the “Aetna Open Access TRS-ActiveCare Select” plan in the “Select a Plan” box.
See page 7 for prescription drugs.
6
ActiveCare Prescription Drugs Summaries and Plan Comparisons
Type of Service
ActiveCare 1-HD Network
ActiveCare Select ActiveCare 2 Network Network
Non-Network
Drug Deductible (per plan year)
Subject to plan year deductible
$0 for generic drugs $200 per individual for brand-name drugs
Same as Network
Retail Short Term (up to 31-day supply) Generic Preferred Brand Non-preferred Brand
20% after deductible
Retail Maintenance (after first fill; up to 31-day supply) Generic Preferred Brand Non-preferred Brand
20% after deductible
Mail Order and Retail-Plus Network (up to 90-day supply) Generic Preferred Brand Non-preferred Brand
20% after deductible
Specialty Medications
20% after deductible
$20 $40 50% coinsurance
$0 for generic drugs $200 per individual for brand-name drugs
$20 $40 $65
$25 $50 50% coinsurance
$25 $50 $80
$45 $105 50% coinsurance
$45 $105 $180
20% coinsurance per fill
$200 per fill (up to 31-day supply $450 per fill (32-day to 90-day supply
Network retail pharmacy services
AC 1-HD: You will be reimbursed the amount that would have been charged by a network pharmacy less the required deductible and coinsurance AC Select: You will be reimbursed the amount that would have been charged by a network pharmacy less the required deductible, copay and coinsurance AC2: You will be reimbursed the amount that would have been charged by a network pharmacy less the required deductible and copay
Retail-Plus Pharmacy Network Retail pharmacies that choose to participate in the Retail-Plus network are able to dispense a 60-day to 90-day supply of medication. You may visit www.trs.state.tx.us/trs-activecare or contact TRS-ActiveCare Customer Service for more information on which pharmacies have chosen to participate in the Retail-Plus network.
Participating network retail pharmacies will accept your TRS-ActiveCare ID card and charge you the lesser of the negotiated Caremark price or the usual and customary cost for up to a 31-day supply of your prescription at a traditional retail network pharmacy, or a 60-day to 90-day supply at a Retail-Plus network pharmacy. For the ActiveCare 1-HD Plan, after your plan year deductible is met, you will pay the applicable coinsurance percentage based on the cost of the prescription until your out-of-pocket maximum is satisfied. For the ActiveCare Select and ActiveCare 2 Plans, after your prescription brand-name drug deductible is met, you will pay any applicable copay or coinsurance percentage based on the cost of the prescription. Your traditional retail pharmacy service is most convenient when you need a medication for a short period. For example, if you need an antibiotic to treat an infection, you can go to one of the many pharmacies that participate in the TRS-ActiveCare program and get your medication on the same day. For your short-term prescriptions, you may save money by using pharmacies that participate in the Caremark network.
Mail order through the Caremark Pharmacy By using the Caremark Pharmacy, you can receive up to a 90-day supply of covered medications. For the ActiveCare 1-HD Plan, after your plan year deductible is met, you will pay the applicable coinsurance percentage based on the cost of the prescription until your out-of-pocket maximum is satisfied. For the ActiveCare Select and ActiveCare 2 Plans, after your prescription brand-name drug deductible is met, you will pay any applicable copay or coinsurance percentage based on the cost of the prescription. The Caremark Pharmacy offers you convenience and potential cost savings. If you need medication on an ongoing or long-term basis, such as medication to treat asthma or diabetes, you can ask your doctor to prescribe up to a 90-day supply for home delivery, plus refills for up to one year.
7
Prescription Drugs
Frequently Asked Questions (FAQs) Prescription drug coverage for ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans
5. I have seen several $4 and $5 generic medication offerings. Can I take advantage of these offers through my pharmacy benefits? Caremark’s claims processing looks at both the Caremark discount and what a cash paying customer would pay at that pharmacy. The lesser of those two amounts is then applied. Plan participants are encouraged to present their Caremark/TRS-ActiveCare ID card when picking up a prescription at a pharmacy as both a safety and cost-savings measure. When the card is presented, the prescription can be assessed for possible drug-to-drug interactions, excessive quantity, etc. The amount paid will also be applied to the participant’s deductible, if any. If the participant fails to show the card, neither safety nor cost-savings activities will occur. Of course, as is the case with any product, consumers are encouraged to shop for the best value for their dollar.
1. How can I find out if my medication is covered? You can find drug coverage and pricing information online at the TRS-ActiveCare website or, once you are enrolled in TRS-ActiveCare, by registering online with Caremark at www.caremark.com/trsactivecare. 2. How do I get a new mail-service prescription filled through Caremark? For new long-term or maintenance medications, ask your doctor to write two prescriptions: • The first for up to a 90-day supply, plus any appropriate refills, to fill through the Caremark Mail-Service Pharmacy.
6. Can Caremark transfer my prescriptions from a retail pharmacy to mail order? You must ask your doctor to provide a new prescription when you request mail order. By law, a 31-day prescription cannot be converted to a 90-day prescription. A new prescription is required. By asking for a 90-day prescription, your doctor can prescribe the maximum days’ supply for your mail order, which is typically 90 days for long-term drugs.
• The second for up to a 31-day supply, which you can fill at a participating retail network pharmacy for use until your mail-service prescription arrives. Complete a Mail-Service Order Form and send it to Caremark, along with your original prescription(s) and the appropriate copayment for each prescription. Be sure to include your original prescription. Photocopies are not accepted. Please note: You must mail in a Caremark Mail-Service Order Form the first time you request a new prescription through mail service. Caremark’s automated refill service is only available after your first prescription order has been processed. You can download a Mail-Service Order Form by visiting www.caremark.com/trsactivecare.
Note: If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug.
3. How do I pay for my mail-service prescriptions? A credit card is preferred, but you can also pay by check or money order. For credit card payments, include your VISA®, Discover ®, MasterCard ® or American Express® number and expiration date in the space provided on the order form.
Note: Registered pharmacists are available 24 hours a day, seven days a week to answer any questions about your medications. Call the toll-free number located on your Caremark card. You can also talk with a registered pharmacist online at www.caremark.com/trsactivecare. Look for the link to “Ask-a-Pharmacist.”
4. When will I receive my mail-service prescription? You can expect to get your prescription 7-10 days from the time your order is placed.
8
How the Medical Plans Work
If you need to…
Network: You pay lower out-of-pocket costs if you choose network care
Non-Network: ActiveCare 1-HD and ActiveCare 2: You pay higher out-of-pocket costs if you choose non-network care. Payment for non-network services is limited to the allowable amount as determined by Aetna. You are responsible for all charges billed by non-network providers that exceed the allowable amount. ActiveCare Select: No coverage for non-network care, except for a true emergency.
Visit a doctor or specialist A “specialist” is any physician other than a family practitioner, internist, OB/GYN or pediatrician
• Visit any network doctor or specialist • Pay the office visit copay (not applicable for ActiveCare 1-HD) • Pay any deductible and coinsurance • Your doctor cannot charge more than the allowable amounts for covered services
ActiveCare 1-HD and ActiveCare 2: • Visit any licensed doctor or specialist • Pay for the office visit • File a claim and get reimbursed for the visit minus any deductible and coinsurance • Your costs will be based on allowable amounts; the non-network doctor you receive services from may require you to pay any charges over the allowable amounts determined by Aetna. ActiveCare Select: No coverage for non-network care
Receive preventive care
• Visit any network doctor or specialist • Plan pays 100% • Your doctor cannot charge more than the allowable amounts for covered services
ActiveCare 1-HD and ActiveCare 2: • Visit any licensed doctor or specialist • Pay for the preventive care visit • File a claim and get reimbursed for the visit minus any deductible and coinsurance • Your costs will be based on allowable amounts; the non-network doctor you receive services from may require you to pay any charges over the allowable amounts determined by Aetna. ActiveCare Select: No coverage for non-network care
Receive emergency care Use the iTriage mobile app to find an urgent care center or emergency room near you. (See page 12 for more information.)
• Call 911 or go to any hospital or doctor immediately; you will receive network benefits for emergency care • Pay any copay (waived if admitted) • Pay any deductible and coinsurance • Call the preauthorization number on your ID card within 48 hours
All plans: • Call 911 or go to any hospital or doctor immediately; you will receive network benefits for emergency care • Pay any copay (waived if admitted) • Pay any deductible and coinsurance • Call the preauthorization number on your ID card within 48 hours
Have lab work
• Visit a Quest Diagnostics facility • ActiveCare Select and ActiveCare 2 Plan pays 100% at Quest; you pay applicable deductible or coinsurance at other facility • ActiveCare 1-HD pay applicable deductible and coinsurance
ActiveCare 1-HD and ActiveCare-2: • Visit any licensed facility • Pay for the lab work • File a claim and get reimbursed for the lab service minus any deductible and coinsurance. • Your costs will be based on allowable amounts; the non-network provider may require you to pay any charges over the allowable amounts determined by Aetna. ActiveCare Select: No coverage for non-network care
Talk to a doctor (Teladoc)
• Call 1-800-Teladoc (835-2362) • Teladoc doctors diagnose non-emergency medical problems, recommend treatment, call in a prescription to your pharmacy of choice • $40 consultation fee for ActiveCare 1-HD; Plan pays 100% for ActiveCare Select and ActiveCare 2
All plans: Not applicable – only available through Teladoc physician service.
Be admitted to the hospital
• Your network doctor will preauthorize your admission • Go to the network hospital • Pay any copays, deductible and coinsurance
ActiveCare 1-HD and ActiveCare 2: • You, a family member, your doctor or the hospital must preauthorize your admission • Go to any licensed hospital • Pay any copays, deductible and coinsurance each time you are admitted ActiveCare Select: No coverage for non-network care
Receive behavioral health or chemical dependency services
• Call the behavioral health number on your ID card first to authorize all care • See a network doctor or health care professional, or go to any network hospital or facility • Pay any copays, deductible and coinsurance
ActiveCare 1-HD and ActiveCare 2: • Call the behavioral health number on your ID card first to authorize all care • See a non-network doctor or health care professional, or go to any non-network hospital or facility • Pay any copays, deductible and coinsurance ActiveCare Select: No coverage for non-network care
File a claim
Claims will be filed for you
You may need to file the claim yourself
Get prescription drugs
• Take prescription to a network retail pharmacy or use Caremark mail service • Pay the required deductible, coinsurance or copay
All Plans: • Take prescription to any licensed pharmacy • Pay the total cost of the drug • File a claim with Caremark and get reimbursed the amount that would have been charged by a network pharmacy less any deductible, copay and coinsurance
9
Tips to Make Your Medical Plan Work for You
Preauthorization
Helpful tips to help you make your health benefits plan work for you.
Advance approval is required from Aetna for certain treatments or services, such as all inpatient hospital admissions, bariatric surgery, extended care expenses, home infusion therapies and outpatient treatment of certain mental health and chemical dependency care. For more information on preauthorization requirements for the ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans, refer to the online benefits booklet at www.trsactivecareaetna.com or call TRS-ActiveCare Customer Service at 1-800-222-9205 and speak to an Aetna Health Concierge.
• Stay in network – Aetna has negotiated discounts with doctors, hospitals and other health care professionals in their network. That usually means lower out-of-pocket costs for you. Network providers will file your claims and cannot charge more than the allowable amounts for covered services. There is no coverage for non-network care under the ActiveCare Select plan. • Use the emergency room (ER) for life-threatening emergencies only – Life-threatening emergencies warrant a trip to the closest ER.
Tools to help you make better health care choices
• Use an urgent care center or walk-in clinic for non-life-threatening emergencies – If it is not a true emergency but you need help in a hurry, please consider visiting an urgent care center or walk-in clinic. You can find them by using the DocFind® online provider directory. Go to www. trsactivecareaetna.com and click “Find a doctor or facility” on the home page. Not sure where to go? Call the 24-Hour Nurse Information Line at 1-800-556-1555 to get guidance from a trained nurse.
Check out these tools to help you with your health care choices. • Member Payment Estimator – This tool lets you find and compare actual costs for common procedures and treatments before you receive care. Your search results are run through Aetna’s claim system, so your out-of-pocket cost will reflect how much of your deductible you have met, and any copays, coinsurance and plan limits that may apply. To find this and other cost-of-care tools, go to www.trsactivecareaetna.com and log in to Aetna Navigator. On your Aetna Navigator home page, you will see a “Cost of Care” box.
• Use generic drugs – They are the most affordable drugs and offer you the lowest copay. Generic drugs are pharmaceutically and therapeutically equivalent to brand-name drugs.
• Aetna Health Concierge – The Aetna Health Concierge can help you understand and use all that your Aetna plan offers, from benefits and providers, to wellness programs and online tools. Call TRS-ActiveCare Customer Service at 1-800-222-9205 and speak to an Aetna Health Concierge.
• Use freestanding medical service facilities – You can generally lower medical expenses by scheduling laboratory work, imaging and other outpatient services at freestanding medical service facilities instead of at full-service hospitals. Remember, you get additional savings when you use a Quest Diagnostics lab. To find them, use DocFind. Go to www.trsactivecareaetna.com and click “Find a doctor or facility” on the home page.
• DocFind – Use DocFind to locate doctors, hospitals, urgent care facilities and other health care providers in your plan’s network. Go to www.trsactivecareaetna.com and click “Find a doctor or facility” on the home page. Once in DocFind, enter a name, specialty, procedure or condition.
• Adopt healthy habits – Do your best to eat right, exercise and get regular health screenings. Sign up for member newsletters or read online articles or health and fitness tips. Encourage all family members to live a healthy lifestyle too.
The ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans offer you resources, tools and services to help you best manage your own and your family’s health care. Be sure to take advantage of them.
• Get online – The ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans offer online services where members can check the status of claims, view benefits information, find a doctor and much more. Go to www.trsactivecareaetna.com and register for Aetna Navigator.
10
Wellness Resources for ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 Plans Helping you live a healthier life Managing your health is more than just doctor visits and lab tests. Aetna provides the following resources so you and your covered family members can reach your health and wellness goals. • 24-Hour Nurse Information Line – Registered nurses are available any time to answer your health-related questions. If an unexpected medical situation arises, a nurse can help you decide if you should call your doctor, or visit the emergency room or an urgent care facility. The nurse can also suggest things you can do until you are able to see your doctor. Call the 24-Hour Nurse Information Line at 1-800-556-1555.
Teladoc® You have phone access to a national network of physicians for non-emergency medical assistance. Teladoc physicians include general practitioners, internists and pediatricians. They can diagnose, treat and prescribe medication for many common medical issues such as the flu. When your doctor’s office is closed or you cannot get to a doctor because of your schedule or location, Teladoc is available by phone, 24 hours a day, 7 days a week.* Call 1-855-Teladoc (835-2362). And, you will save time and money. The consult is covered at 100% for ActiveCare Select and ActiveCare 2. You will also save under the ActiveCare 1-HD plan. *Not available in Idaho per state regulations.
• The Aetna Care Advocate Team (CAT) – This is a group of trained nurses who can guide you through the health care system. With CAT, you can get help to understand a medical condition or term. You can find out about treatment options. You can also have a nurse coordinate care and services for a complex condition.
• Simple Steps To A Healthier Life® – Start by taking an online Health Assessment to learn more about your current state of health and any risks you may be facing. You will then get a health score, health report and action plan that includes online wellness programs tailored to your needs. These programs provide “simple steps” you can take to eat healthier, lose weight, quit tobacco, manage stress, deal with depression and get a better night’s sleep without medication. To get started, visit www.trsactivecareaetna.com and log in to Aetna Navigator (see page 12). On your Aetna Navigator home page, click “I want to . . . Take a Health Assessment.”
• The Beginning Right® Maternity Program – Talk with trained nurses who can help you give your baby a healthier start in life. Learn about prenatal care, preterm labor, newborn care and more. Get personal attention for special needs, risks or conditions. Call 1-800-272-3531 to learn more and get started. You can also find more information at www.trsactivecareaetna.com. • The National Medical Excellence® Program – Provides care coordination and other services to Aetna members facing transplant surgery or other complex medical procedures. Participation is entirely voluntary. If you choose to participate, your procedure will be performed at a designated Institutes of ExcellenceTM hospital chosen for its experience and outcomes with organ transplants and complex medical care. The program also provides expert case management and coordination of follow-up care.
Get Help to Quit Tobacco One of the best things you can do for your health is to quit tobacco – and Aetna can help. One of the HealthMedia® online wellness programs that is part of Simple Steps To A Healthier Life is BREATHE®, a smoking cessation program. With BREATHE, you can get help and support to quit tobacco and stay quit. Step by step, you will learn how to reduce cravings, resist relapse and feel healthier.
• Aetna Discount Program – As an Aetna member, you and your covered family members are eligible for discounts on health-related products and services. Get special rates on vision and hearing care, gym memberships and fitness equipment, weight management programs and products, natural products and services, and more.
• Condition Management – If you or a family member has been diagnosed with one or more chronic conditions, Aetna Health Connections can provide one-on-one help and support. Registered nurses and other health care professionals work with you and your doctor to provide education, coaching and monitoring to help you manage your condition and enjoy better overall health. The program covers more than 30 conditions, including asthma, high blood pressure, diabetes, heart disease, osteoporosis, chronic obstructive pulmonary disorder and more.
Get help to practice prevention With Preventive Care Considerations, you get direct mail and email reminders to get preventive services appropriate for your age and gender. These can include yearly physical exams, mammograms, colonoscopies and other services.
11
Wellness Resources for ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 Plans Your secure member website
• Health and physical activity trackers that let you record important information and measures such as blood pressure, blood glucose, strength training and other daily fitness activities.
Aetna Navigator is where you will find information and tools to make the most of your plan benefits and better manage your health care and health dollars. It is easy to register and use the site.
To view your PHR, Go to www.trsactivecareaetna.com and log in to Aetna Navigator. In the “I want to …” menu on the left side of your Aetna Navigator home page, select “View Personal Health Record.”
To register: Visit www.trsactivecareaetna.com and click “Log In/Register” on Aetna Navigator. Follow the simple prompts. Need help? Use the “Ask Ann” link to register, retrieve a password and find your way around the site. Once you are registered, you can: • Check benefits and claims • Search for doctors who participate in the Aetna network • Find hours and locations of urgent care centers • Confirm family members covered under your plan • Request a new or replacement Aetna ID card or print a temporary card • Get cost estimates for medical procedures and treatments • Take the Health Assessment • View your Personal Health Record • Get started with Aetna discounts on hearing and vision care, fitness memberships and much more • Link to reliable health information with Aetna InteliHealth® and Aetna SmartSourceSM and much more
Mobile apps and tools
Make Aetna Navigator your first stop when you need to know more about your benefits and other resources available for your good health.
• Access Aetna Navigator on the go with Aetna Mobile. Pull up your secure member website to find network doctors, view and show your ID card, check on claims, contact Member Services and more. The Aetna Mobile app works with Apple® mobile digital devices and Android™-powered phones.* Get it: Text “Apps” to 44040** OR visit www.aetna.com/mobile. • CarePass® connects you to health and fitness apps you will love. Set goals and track your nutrition, fitness, health and sleep all in one place. Get started with FitBit ®, Lose It!, Body Media®, Zipongo and others. Get it: Go to www.trsactivecareaetna.com, log in to Aetna Navigator, then click the link on your Aetna Navigator home page to “Get started with CarePass.” • iTriage helps you make sense of your health care options. Check a symptom, look up conditions and procedures, find the right doctor or facility, look up ER wait times and much more. Get it: The app is free on Google Play or the App Store;* you can also visit www.itriagehealth.com.
Personal Health Record
• The Caremark app gives you real-time, secure access to your prescriptions and pharmacy information. Look up pharmacies near you. Order prescriptions using the mail service, then check on the status of your order. Check your prescription history. You can use the app on your iPhone® or Android phone.*
Aetna Navigator is where you will find your Personal Health Record (PHR), an online record of care you have received, gathered from your claims information. You can view medical procedures and services received, and preventive and routine care provided – by whom and when. You can also enter your own information, such as medications prescribed, over-the-counter drugs and nutritional supplements you use. The PHR also features:
Get it: Visit www.caremark.com. On the home page, look for the More Mobile Choices link to “get your App now.”
• MedQuery®, an advanced program that can identify opportunities for better care and better health. MedQuery works for you by sending personal health recommendations and alerts that appear on your PHR.
*Android and Google Play are trademarks of Google, Inc. Apple, and iPhone are trademarks of Apple, Inc., registered in the U.S. and other countries. The App Store is a service mark of Apple, Inc. **Standard text messaging rates may apply.
12
HMO Benefits Summaries and Plan Comparisons
HMO Benefits Summaries and Plan Comparisons
Type of Service No primary care physician required to direct care or make referrals
No primary care physician required to direct care or make referrals
No primary care physician required to direct care or make referrals
Deductible (per plan year)
$450 individual $1,125 family
$1,000 individual $3,000 family
$500 individual $1,000 family
Out-of-Pocket Maximum (per plan year; includes medical deductibles/copays/coinsurance)
$4,450 individual $9,125 family
$4,000 individual $9,000 family
$4,500 individual $9,000 family
Doctor Office Visits
$20 copay for primary $60 copay for specialist
$20 copay for primary $50 copay for specialist
$25 copay for primary $60 copay for specialist
Preventive Care
Plan pays 100%
Plan pays 100%
Plan pays 100%
Inpatient Hospital (facility charges)
25% after deductible
$150 copay per day plus 20% after deductible ($750 maximum copay per admission)
20% after deductible
Inpatient Hospital (physician/surgeon fees)
25% after deductible
Included in facility charges
20% after deductible
Outpatient Surgery
25% after deductible
$150 copay per visit plus 20% after deductible
20% after deductible
Ambulance
25% after deductible
$40 copay plus 20% after the deductible ($40 copay waived if transported)
20% after deductible
Emergency Room
25% after deductible
$150 copay plus 20% after deductible (copay waived if admitted within 24 hours)
20% after deductible
Urgent Care
$75 copay (deductible waived)
$55 copay
$75 copay (deductible waived)
Maternity Care
Prenatal and Postnatal Care $20 copay for primary $60 copay for specialist
Prenatal No charge
Prenatal and Postnatal Care $25 copay for primary $60 copay for specialist
Delivery and Inpatient Services 25% after deductible
Postnatal Care $20 copay for primary $50 copay for specialist Delivery and Inpatient Services $150 copay per day plus 20% after deductible ($750 maximum copay per admission)
Delivery and Inpatient Services 20% after deductible
Outpatient Services 25% after deductible (facility) $20 (physician office visit)
Outpatient Services $20 copay for physician
Outpatient Services 20% after deductible $60 (specialist office visit copay)
Inpatient Services 25% after deductible
Inpatient Services $150 copay per day plus 20% after deductible ($750 maximum copay per admission)
Inpatient Services 20% after deductible
Drug Deductible (per plan year)
$100 per individual/$300 per family
$100 per individual (generics excluded)
$100 per individual
Retail Short Term
(up to 30-day supply) $10 – Generic Tier I (drug deductible waived) $30 – Preferred Tier II after drug deductible $60 – Non-preferred Tier III after drug deductible
(up to 34-day supply) $3 – Generic 30% after deductible – Preferred 50% after deductible – Non-preferred Greater of $50 or 50% after deductible – Non-formulary
(up to 30-day supply) $10 – Generic $40* – Preferred $65* – Non-preferred
Retail Maintenance
(up to 30-day supply) $10 – Generic Tier I (drug deductible waived) $30 – Preferred Tier II after drug deductible $60 – Non-preferred Tier III after drug deductible
(up to 90-day supply; in-plan pharmacies only) $6 – Generic 30% after deductible – Preferred 50% after deductible – Non-preferred Not available – Non-formulary
(up to 90-day supply at participating pharmacies) $30 – Generic $120* – Preferred $195* – Non-preferred
Mail Order
(up to 90-day supply) $30 – Generic Tier I (drug deductible waived) $90 – Preferred Tier II after drug deductible $180 – Non-preferred Tier III after drug deductible
(up to 90-day supply; in-plan pharmacies only) $6 – Generic 30% after deductible – Preferred 50% after deductible – Non-preferred Not available – Non-formulary
(up to 90-day supply) $30 – Generic $120* – Preferred $195* – Non-preferred
Specialty Medications (Tier IV)
20% after drug deductible
10% after deductible – Tier I 20% after deductible – Tier II 30% after deductible – Tier III 50% after deductible – Tier IV
20% after deductible Mail order – Not covered
Diabetic Supplies
10% – Preferred after drug deductible 20% – Non-preferred after drug deductible
Mental Health/Behavioral Health/Substance Abuse Disorders
13
Note: *If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brandname drug and the generic drug.
Note: This is a general summary of your HMO plan options. Please refer to your Evidence of Coverage for details specific to your plan.
See page 15 for HMO service areas.
14
HMO Plan Service Areas
Customer Service 1-800-884-4901 8 a.m. – 6 p.m. CT (Mon-Fri)
Customer Service 1-800-321-7947 or 254-298-3000 24 hours a day 7 days a week
Customer Service 1-855-463-7264 8 a.m. – 5 p.m. CT (Mon-Fri)
Service Area – Counties
Service Area – Counties
Service Area – Counties
Andrews, Armstrong, Bailey, Bell, Borden, Bosque, Brazos, Briscoe, Burleson, Burnet, Callahan, Carson, Castro, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Coryell, Cottle, Crane, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Erath, Falls, Fisher, Floyd, Freestone, Gaines, Garza, Glasscock, Gray, Grimes, Hale, Hall, Hamilton, Hansford, Hartley, Haskell, Hemphill, Hill, Hockley, Houston, Howard, Hutchinson, Jones, Kent King, Knox, Lamb, Lampasas, Lee, Leon, Limestone, Lipscomb, Llano, Loving, Lubbock, Lynn, Madison, Martin, McCulloch, McLennan, Midland, Milam, Mills, Mitchell, Moore, Motley, Navarro, Nolan, Ochiltree, Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Robertson, Runnels, San Saba, Scurry, Shackelford, Sherman, Somervell, Stephens, Stonewall, Swisher, Taylor, Terry, Throckmorton, Upton, Walker, Ward, Washington, Wheeler, Winkler, Yoakum
Austin, Bastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Coke, Coleman, Concho, Coryell, Crockett, Falls, Freestone, Grimes, Hamilton, Hayes, Hill, Hood, Irion, Johnson, Kimble, Lampasas, Lee, Limestone, Llano, Madison, Mason, McCullough, McLennan, Menard, Milam, Mills, Reagan, Robertson, Runnels, San Saba, Schleicher, Sommervell, Sterling, Sutton, Tom Green, Travis, Walker, Waller, Washington, Williamson
Cameron, Hidalgo, Starr, Willacy
As well as these partial counties: Includes zip codes (*zip codes may cross into a non-covered county) Erath – 76433 76436 76446* 76457 76401* 76690 Leon – 75833* 77855 75850* 77865* 77871
Geographical description of partial counties: Erath – the southeastern one-half of the county below U.S. Highway 377 southwest from the Hood County line to the Comanche County line but including the towns of Bluff Dale, Stephenville and Dublin Leon – the southwestern one-fourth of the county bounded on the north by Texas Highway 7 east from the Robertson County line to Texas Highway 75 and bounded on the east by Texas Highway 75 south from Texas Highway 7 to the Madison County line but including the towns of Marquez, Robbins, Centerville and Leona
15
HMO Wellness Resources
FirstCare Plus At FirstCare Health Plans, we believe that Texans and our communities should be healthy. That is why we developed FirstCare Plus, which is a unique set of integrated programs and services that keep you connected to your health.
MyBenefits – Online Tools: Log in to MyBenefits at trs.swhp.org
• Our wellness program offers an array of tools, including: online health assessment, alerts, information, and wellness trackers.
• Order ID cards
• The 24-hour Nurseline and online nurse chat provides help day or night.
VitalCare – An Approach to Health and Wellness 24-Hour Nurse Advice Line – 1-877-505-7947
• Our disease management program provides support to those with chronic conditions. Get specialized help from health coaches to achieve better outcomes.
Online lifestyle management programs
FirstCare Member Portal Log in to the member portal a www.firstcare.com
The Dialog Center Condition Care Guidance Programs Health Coaches are available to answer your health questions by phone, anytime day or night – 1-877-505-7947. Or visit www.trs.swhp.org (select VitalCare Health and Wellness Coaching) to see videos for Shared Decision-Making, look up health topics or email your health coach.
• Find a doctor or pharmacy with our new online provider directory • View or print plan documents • Order ID cards or print a temporary one • Access FirstCare Plus tools and information
• Find a provider or pharmacy • View the Summary of Benefits (SOB/SBC) • View Explanation of Benefits (EOB) • Access online wellness programs
• Succeed Health Risk Assessment • 9 additional wellness programs
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A listing of “Preventive Health Care Services,” that are available to all enrolled members, can be found in your Evidence of Coverage. These services are available at no cost to the enrolled member, and can be found in Section 3 of the Evidence of Coverage which is titled “What is Covered.” Healthy Partners Program is a program designed to assist members with diabetes. Through the program, members are able to obtain their diabetic supplies at no cost and have access to a case manager who assists in information/referral to community resources and educational services/ referrals via internet sources or subsidiary programs. We believe improved monitoring will assist you and your physician to optimize control of your blood sugars and decrease long-term complications associated with poorly controlled diabetes. Enroll by calling 956-389-4471.
Cost for Coverage
Cost for coverage
Pooling Funds/Split Premium
Your cost for TRS-ActiveCare coverage is determined by the funding available from the state and district as well as your choice of a health plan, which determined your deductibles, copayments, coinsurance and your monthly contributions.
Married employees who are both active contributing TRS members may “pool” their local district and state funding to use toward the cost of TRS-ActiveCare coverage. If a husband and wife both work for the same participating entity, funds may be pooled when one selects “employee and other” coverage or “employee and family” coverage and the spouse declines coverage.
Chapter 1581, Texas Insurance Code, authorizes funding to help active employees who are TRS members—those making retirement contributions to the Teacher Retirement System of Texas—pay for TRS-ActiveCare coverage. Currently, each district/entity is required to contribute at least $150 per month and the state currently contributes $75 per month per active TRS member. That is a minimum of $225 per month to help you pay for health coverage. Your Benefits Administrator will provide you with information on any additional funding that may be available to offset the gross monthly premiums.
If a husband and wife work for different participating entities and wish to pool funds, with the help of his/her Benefits Administrator must complete an Application to Split Premium. This form should be submitted to each Benefits Administrator with the Enrollment Application and Change Form. To download the Application to Split Premium, visit the TRS-ActiveCare website or call Customer Service.
Gross Monthly Cost – 2014-2015 Plan Year Effective September 1, 2014 through August 31, 2015 ActiveCare Plans
ActiveCare 1-HD
ActiveCare Select
ActiveCare 2
Total Cost*
Total Cost*
Total Cost*
Employee Only
$325
$450
$555
Employee and Spouse
$850
$1,044
$1,287
Employee and Child(ren)
$572
$709
$875
$1,145
$1,238
$1,323
HMO Plans
FirstCare Health Plans
Scott & White Health Plan
Coverage Category
Total Cost*
Total Cost*
Total Cost*
Coverage Category
Employee and Family
Allegian Health Plans
(formerly Valley Baptist Health Plans)
Employee Only
$390.14
$452.80
$400.20
Employee and Spouse
$977.76
$1,020.08
$969.60
Employee and Child(ren)
$618.94
$717.32
$627.14
Employee and Family
$987.44
$1,131.50
$989.22
* 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.
17
Enrollment
period for The plan enrollment year is the 2014-2015 plan 2014. July 21-August 31,
Who can enroll in TRS-ActiveCare? To be eligible for TRS-ActiveCare, you must be employed by a participating district/entity and be either an active, contributing TRS member or employed 10 or more regularly scheduled hours each week.
• “Any other child” under the age of 26 in a regular parent-child relationship with the employee (other than a child described in the category immediately above), meeting all four of the following requirements:
You are not eligible for TRS-ActiveCare coverage if you are:
1. The child’s primary residence is the household of the employee;
• Receiving health care coverage as an employee or retiree under the Texas State College and University Employees Uniform Insurance Benefits Act. Example: A school employee who has UT SELECT coverage as an employee with The University of Texas System.
2. The employee provides at least 50% of the child’s support;
• Receiving health care coverage as an employee or retiree under the Texas Employee Uniform Group Insurance Benefits Act. Example: A school employee who has HealthSelect coverage as an employee with ERS.
• A grandchild under age 26 whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect.
• A TRS retiree receiving, or who waived coverage under, TRS-Care, including a retiree who has returned to work.*
• A child (age 26 or over) of a covered employee, may be eligible for dependent coverage, provided that the child is either mentally or physically incapacitated to such an extent to be dependent on the employee on a regular basis as determined by TRS, and meets other requirements as determined by TRS.
3. Neither of the child’s natural parents resides in that household; and 4. The employee has the legal right to make decisions regarding the child’s medical care.
*If a TRS retiree has returned to work and has never been eligible for TRS-Care, he or she would be eligible for TRS-ActiveCare coverage, as long as the retiree meets all the TRS-ActiveCare eligibility requirements.
Note: The employee (and the dependent’s attending physician) must complete a Request for Continuation of Coverage for Handicapped Child form and Attending Physician’s Statement to provide satisfactory proof of the disability and dependency. The forms are available on the TRS-ActiveCare website at www.trsactivecareaetna.com and must be submitted no later than 31 days after the date the child turns 26. To avoid any gap in coverage, the form must be submitted and approved prior to the end of the month the child turns 26.
Although a retiree, a higher education employee or a state employee may not be covered as an employee of a participating district/entity, he or she can be covered as a dependent of an eligible employee.
Note: Under Section 22.004, Texas Education Code, and TRS rules, an employee who is participating in TRS-ActiveCare is entitled to continue participating in TRS-ActiveCare if the employee resigns after the end of the instructional year and at the time of the effective date of the resignation, is in good standing with TRS-ActiveCare. TRS Rule 41.38, Texas Administrative Code, will be applied by TRS-ActiveCare in determining the appropriate termination date of TRS-ActiveCare coverage. This is important when planning for retirement and determining when your TRS-Care coverage will begin. Discuss your options for health coverage with your employer when planning for retirement.
A dependent does not include a brother or a sister of an employee unless the brother or sister is an individual under 26 years of age who is either: (1) under the legal guardianship of an employee, or (2) in a regular parent-child relationship with an employee, as defined in the “any other child” category above. Parents and grandparents of the covered employee, do not meet the definition of an eligible dependent. Note: It is against the law to elect coverage for an ineligible person. Violations may result in prosecution and/or expulsion from the TRS-ActiveCare program for up to five years.
Eligible dependents include: • Your spouse (including a common law spouse)
What is CHIP and is it available to my family?
• A child under the age of 26, who is one of the following:
Currently, families may qualify for low-cost children’s health insurance through the Children’s Health Insurance Program (CHIP). To apply, call CHIP at 1-800-647-6558, 211 or log in to www.chipmedicaid.org
A natural child
An adopted child or a child who is lawfully placed for legal adoption A stepchild
Note: A child cannot receive coverage under both TRS-ActiveCare and CHIP.
A foster child A child under the legal guardianship of the employee
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Enrollment
How to enroll Follow these steps to enroll: New Hires – New hires have 31 calendar days after the first day of employment to select health coverage through TRS-ActiveCare. New hires may choose their actively-at-work date (the date they start to work) or the first of the month following their actively-at-work date as their effective date of coverage. If choosing the actively-at-work date, full premium for the month will be due; premiums are not prorated.
1. Using the information included in this Guide as well as employee contribution amounts provided by your district/entity, choose the health plan option that is right for you. 2. If you are presently enrolled in ActiveCare 1-HD or ActiveCare 2 and you do not want to change your plan or your coverage (Employee Only, Employee plus Spouse, Employee and Children or Employee plus Family) you do not need to do anything. Your elections from last year will carry forward to this year. 3. ActiveCare 3 is being discontinued. Therefore, if you are presently enrolled in ActiveCare 3, you will be automatically enrolled in the ActiveCare 2 plan. If you do not want to be enrolled in ActiveCare 2, you must enroll in another plan. Follow directions below in 4 (a. and b.).
For districts/entities not using the WellSystems enrollment portal, the Enrollment Application and Change Form is available online or from your Benefits Administrator
4. If you want to make a change, your district/entity will tell you the steps to enroll using one of the available options:
1. Visit the TRS web site at www.trsactivecareaetna.com.
You can complete the online version as follows:
2. On the top of the home page, click on “Documents & Forms.”
a. New this year is the ability to enroll online through WellSystems. WellSystems, a specialty partner of Aetna, provides user-friendly tools for enrollment. You will be provided with instructions for logging into the web portal and will be walked through the process. If you are currently covered, you will find your information including address, dependents, plan and coverage type already entered. The system will allow you to change your address, who you are covering and your plan. You can print a confirmation of your enrollment when you are finished.
3. The Enrollment Application and Change Form is the first form listed. Click on it. 4. Enter your information in the application. Please make sure to provide and complete all of the information requested. 5. Print the application. 6. Sign, date and submit the application to your Benefits Administrator.
b. You can also enroll or change your enrollment using the Enrollment Application and Change Form available from your Benefits Administrator or on the TRS-ActiveCare website at www.trsactivecareaetna.com. Submit the completed, signed and dated form to your Benefits Administrator within the required enrollment period(s).
Who needs to enroll or change via the WellSystems enrollment portal or complete an Enrollment Application and Change Form? • New hires enrolling or declining TRS-ActiveCare coverage • Employees enrolling for TRS-ActiveCare coverage with a different participating district/entity
5. Even if you are not accepting available coverage through TRS-ActiveCare, please complete sections 1, 2 and 6 of the Enrollment Application and Change Form and note that you are declining health coverage for yourself and/or your dependents.
• Employees already enrolled, but making changes such as:
Note: Some districts/entities may offer electronic enrollment through a web portal other than WellSystems. If so, you will not need to use the WellSystems enrollment portal or submit an Enrollment Application and Change Form. See your Benefits Administrator for details. Please keep a copy of any confirmation of coverage you receive from the other electronic enrollment system.
Selecting a different TRS-ActiveCare plan option*
Adding or dropping dependents
Choosing to cancel or decline coverage
Changing name or address or correcting date of birth or social security number
• If you plan to keep the same TRS-ActiveCare coverage, you do not need to submit an Enrollment Application and Change Form unless you are transferring to a new participating district/entity. Forms should be returned to your Benefits Administrator. If you do not change your election through the WellSystems enrollment portal or return your Enrollment Application and Change Form, you will automatically be enrolled in the same plan you elected for 2013-2014 (ActiveCare 1-HD or ActiveCare 2) at the same level of coverage. If you are enrolled in ActiveCare 3, you will automatically be enrolled in ActiveCare 2 for 2014-2015 plan year. Please pay close attention to any benefit changes from last year as you make your plan choices. Your employee contribution will be adjusted to reflect any rate change that becomes effective on September 1, 2014.
If you are enrolling in TRS-ActiveCare for the first time, you will need to enroll online through the WellSystems enrollment portal or complete, sign and submit an Enrollment Application and Change Form to your Benefits Administrator before: • The end of the plan enrollment period, or • 31 calendar days after your actively-at-work date, or • 31 calendar days after a special enrollment event (Special rules apply to adding newborns; see page 20 for more information)
*Remember: if you are currently enrolled in ActiveCare 3 and do not want to be transitioned to ActiveCare 2, you must actively enroll in another plan option.
19
Enrollment
Making changes/special enrollment events
What if I choose not to enroll in TRS-ActiveCare? TRS believes it is very important for everyone to have health coverage. Please keep in mind that if you decline coverage in TRS-ActiveCare, you will not be able to elect coverage in TRS-ActiveCare during the plan year unless you have a special enrollment event, such as a marriage, birth or adoption of a child or a loss of other coverage. To decline coverage: Follow the instructions in the WellSystems enrollment portal or complete sections 1, 2 and 6 of the Enrollment Application and Change Form to voluntarily decline coverage for yourself and any of your dependents and to provide the reason for declining. Sign and submit the form to your Benefits Administrator.
During the plan year, you can only change plan options or add or change a covered person if you or a dependent have a special enrollment event. Examples of a special enrollment event include gaining a new dependent through marriage, birth, adoption or placement for adoption, or if an individual with other health insurance coverage involuntarily loses that coverage.
Note: An employee cannot change plans when dropping a dependent from TRS-ActiveCare coverage.
Any decision you make, including the decision not to enroll, stays in effect for the entire plan year, unless you have a special enrollment event.
Changes in employee and/or dependent coverage must be made within 31 calendar days after the special enrollment event. It is your responsibility to meet any such deadlines. If you do not request the appropriate changes during the applicable special enrollment period, the changes cannot be made until the next plan enrollment period or, if applicable, until another special enrollment event occurs.
Note: If you enroll during the year due to “loss of other coverage,” via the WellSystems enrollment web portal or submit an Enrollment Application and Change Form, your original application will be checked to verify that coverage was declined (in the web portal or in section 6 of the Form) due to other coverage.
For more information on special enrollment events, please refer to the Benefits Booklet or Evidence of Coverage for your plan.
How are newborns covered by TRS-ActiveCare? TRS-ActiveCare automatically provides coverage for a newborn child of a covered employee for the first 31 days after the date of birth. To add coverage for the newborn, you must either enroll the child through the WellSystems Enrollment Portal or sign, date and submit an Enrollment Application and Change Form to your Benefits Administrator within 60 days after the date of birth. However, you have up to one year after the newborn’s date of birth to add the newborn to coverage if you had “employee and family” or “employee and child(ren)” coverage with TRS-ActiveCare at the time of the newborn’s birth. The effective date of coverage for the newborn child is the date of birth. If the enrollment via WellSystems Enrollment Portal or completed Enrollment Application and Change Form is submitted after the enrollment period for the newborn child, the request to add coverage will be denied – even if there would be no change in premium. Even though the employee has more time to add a newborn to coverage as described immediately above, changing plans must be done within 31 days after the newborn’s date of birth (and the plan change becomes effective the first of the month following the date of birth). Note: Newborn grandchildren are not automatically covered by TRS-ActiveCare for the first 31 days; however, a covered employee may enroll eligible newborn grandchildren within 31 days after the newborn’s date of birth. It is not necessary to wait for the newborn’s social security number to enroll. To add coverage, you should use the WellSystems Enrollment Portal or submit an Enrollment Application and Change Form without the newborn’s social security number, then update the enrollment record via the WellSystems Enrollment Portal or by submitting another Enrollment Application and Change Form once the number has been issued. For more information about the newborn and eligible dependent’s effective date of coverage and the amount of monthly premium, please refer to the Benefits Booklet or Evidence of Coverage for your plan.
20
Important Notices
Initial notice about special enrollment rights in your group health plan Loss of coverage as a result of a lifetime limit on all benefits
A federal law called Health Insurance Portability and Accountability Act (HIPAA) requires that we notify you about a very important provision in the program. You have the right to enroll in the program under its “special enrollment provisions” if (I) you acquire a new dependent or if (II) you decline coverage under this program for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.
You or your spouse or dependents may also have special enrollment rights in this program at the time a claim is denied by another group health program as a result of a lifetime limit on all benefits in the other group health program. However, you must request enrollment, and Aetna must receive your request, within 31 days after the claim has been denied by the other group health program.
Special enrollment provisions
New dependent by marriage, birth, adoption or placement for adoption
Loss of other coverage (excluding Medicaid or a state Children’s Health Insurance Program)
If you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents in this program. However, you must request enrollment, and Aetna must receive your request, within 31 days after the marriage, birth,* adoption or placement for adoption.
If you are declining enrollment for yourself or your eligible dependents (including your spouse) because of other available group health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this program if you or your dependents lose eligibility for that other coverage (or if you move out of an HMO service area, or the employer stops all contributions towards other coverage for you and your dependents). However, you must request enrollment, and Aetna must receive your request, within 31 days after coverage ends for you or your dependents (or you move out of the prior plan’s HMO service area, or after the employer stops all contributions toward the other coverage, including employer paid COBRA paid premiums).
*Special rules apply to newborns; refer to your TRS-ActiveCare Benefits Booklet or the HMO’s Evidence of Coverage. Eligibility for state premium assistance for enrollees (HIPP) of Medicaid or a state Children’s Health Insurance Program If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state Children’s Health Insurance Program with respect to coverage under this program, you may be able to enroll yourself and your dependents in this program. However, you must request enrollment, and Aetna must receive your request, within 60 days after the determination is made concerning eligibility for such assistance for you or your dependents.
Loss of coverage for Medicaid or a state Children’s Health Insurance Program If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under the Texas Children’s Health Insurance Program (CHIP) is in effect, you may be able to enroll yourself and your dependents in this program if you or your dependents lose eligibility for that other coverage. However, you must request enrollment, and Aetna must receive your request, within 60 days after your or your dependents’ coverage ends under Medicaid or a state Children’s Health Insurance Program.
Additional Information To request special enrollment or obtain more information, call the TRS-ActiveCare Customer Service phone number on the back of your TRS-ActiveCare ID card.
21
Important Notices
Medicare Beneficiaries and Medicare Part D
Notice of Privacy Practices
Effective January 1, 2006, a Medicare prescription drug plan, called Medicare Part D, provides Medicare benefits for prescription drugs to those Medicare beneficiaries who enroll in Part D. Medicare Part D is an optional benefit and is available only to individuals who have Medicare Part A and/or Part B. TRS-ActiveCare coverage will not be affected by enrollment in Medicare Part D for these individuals. That is, your TRS-ActiveCare coverage will continue to be your primary coverage; Medicare Part D will be secondary. However, the TRS-ActiveCare plan you have may influence your decision on whether or not to enroll in Medicare Part D. The Centers for Medicare & Medicaid Services (CMS) administers Medicare and a link to their website is available on the TRS-ActiveCare page of the TRS website: www.trs.state.tx.us. If you or your dependent is covered by TRS-ActiveCare and is at least age 65, you will receive additional information on Medicare Part D from TRS (if covered by ActiveCare 1-HD, ActiveCare Select, or ActiveCare 2) or from your HMO plan before the end of the calendar year 2014.
The Teacher Retirement System of Texas (TRS) administers your health benefits plan and your pension plan pursuant to federal and Texas law. This notice is required by the Privacy Regulations adopted pursuant to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH). This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. This notice also sets out TRS’ legal obligations concerning your health information. Additionally, this notice describes your rights to control your health information. Please contact in writing the Privacy Officer, at the following address, if you have questions or want additional information about the privacy practices described in this notice: Privacy Officer Teacher Retirement System of Texas 1000 Red River Street Austin, Texas 78701
For Medicare-eligible individuals and individuals expecting to be Medicare-eligible this plan year: • The ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans have been determined to be creditable coverage for Medicare Part D purposes under current Medicare guidelines. • Each HMO has determined that the coverage it is offering is creditable coverage for Medicare Part D purposes under current Medicare guidelines.
• Disclosure notices are posted on the Creditable Coverage web page at http://www.cms.hhs.gov/creditablecoverage.
Federal law requires TRS to maintain and protect the privacy of your health information. Your protected health information is individually identifiable health information, including genetic information and demographic information, collected from you or created or received by TRS that relates to: • Your past, present or future physical or mental health or condition; • The health care you receive; or • The past, present or future payment for the provision of health care for you.
• Questions about Medicare Part D should be directed to Medicare at 1-800-MEDICARE (1-800-633-4227).
Unsecured protected health information is protected health information that is not secured through the use of a technology or methodology that renders the protected health information unusable, unreadable or indecipherable.
The effective date of this notice was April 14, 2003 and has been revised effective April 1, 2013. Texas law already makes your member information, including your protected health information, confidential. Therefore, following the original implementation of this notice and the implementation of this notice as revised, TRS did not and is not changing the way that it protects your information. On April 14, 2003, the new rights and other terms in this notice, as originally drafted, automatically applied. Likewise, as subsequently revised, the rights and other terms of this notice continue to automatically apply. You do not need to do anything to get privacy protection for your health information.
22
Important Notices
• When federal, state or local law, judicial or administrative proceedings, or law enforcement requires a use or disclosure. For example, upon receipt of your request for disability retirement benefits, TRS and members of the Medical Board may use your protected health information to determine if you are entitled to a disability retirement. TRS may disclose your protected health information:
Federal law requires that TRS provide you with this notice about its privacy practices and its legal duties regarding your protected health information. This notice explains how, when and why TRS uses and discloses your protected health information. By law, TRS must follow the privacy practices that are described in the most current privacy notice. TRS reserves the right to change its privacy practices and the terms of this notice at any time. Changes will be effective for all of your protected health information that TRS maintains. If TRS makes an important change that affects what is in this notice, TRS will mail you a new notice within 60 days of the change. This notice is on the TRS website, and TRS will post any new notice on its website at www.trs.state.tx.us.
How TRS may use and disclose your protected health information
To a federal or state criminal law enforcement agency that asks for the information for a law enforcement purpose;
To the Texas Attorney General to collect child support or to ensure health care coverage for your child;
In response to a subpoena if the TRS Executive Director determines that you will have a reasonable opportunity to contest the subpoena;
Certain uses and disclosures do not require your written permission.
For any use or disclosure of your protected health information that is described immediately below, TRS and/or Medical Board members, auditors, actuarial consultants, lawyers, health plan administrators or pharmacy benefit managers acting on behalf of TRS, TRS-Care or TRS-ActiveCare may use and disclose your protected health information without your written permission (an authorization).
To the Texas Legislature or agencies of the state or federal government, including, but not limited to health oversight agencies for activities authorized by law, such as audits; investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities. Oversight agencies seeking this information include government agencies that oversee: (i) the health care system, (ii) government benefit programs, (iii) other government regulatory programs, and (iv) compliance with civil rights laws;
To a public health authority for the purpose of preventing or controlling disease; and
If required by other federal, state or local law.
For all activities that are included within the definitions of “payment,” “treatment” and “health care operations” as set out in 45 C.F.R. Section 164.501, including the following noted below. This notice does not contain all of the activities found within these definitions; refer to 45 C.F.R. Section 164.501 for a complete list. When “TRS” is used below in describing these reasons, the auditors, actuarial consultants, lawyers, health plan administrators and pharmacy benefit managers acting on behalf of TRS, TRS-Care or TRS-ActiveCare are intended to be included. • For treatment. TRS is not a medical provider and does not directly participate in decisions about what kind of health treatment you should receive. TRS also does not maintain your current medical records. However, TRS may disclose your protected health information for treatment purposes. For example, TRS may disclose your protected health information if your doctor asks that TRS disclose the information to another doctor to help in your treatment.
To a governmental entity, an employer, or a person acting on behalf of the employer, to the extent that TRS needs to share the information to perform TRS’ business;
• For specific government functions. TRS may disclose protected health information of military personnel and veterans in certain situations. TRS may also disclose protected health information to authorized federal officials for conducting national security, such as protecting the President of the United States, or conducting intelligence activities, or to the Texas Legislature or agencies of the state or federal government, including, but not limited to health oversight agencies, for activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, civil, administrative, or criminal proceedings or actions, or other activities. Oversight agencies seeking this information include government agencies that oversee: (i) the health care system, (ii) government benefit programs, (iii) other government regulatory programs, and (iv) compliance with civil rights laws.
• For payment. Here are two examples of how TRS might use or disclose your protected health information for payment: First, TRS may use or disclose your information to prepare a bill for medical services to you or another person or company responsible for paying the bill. The bill may include information that identifies you, the health services you received, and why you received those services. Second, TRS could use or disclose your protected health information to collect your premium payments.
• Business associates. TRS has contracts with individuals and companies (business associates) that help TRS in its business of providing health care coverage and in making disability retirement benefit decisions. For example, several companies assist TRS with the TRS-Care and TRS-ActiveCare programs: Aetna, Caremark, Express Scripts and Gabriel, Roeder, Smith and Company. Some of the functions these companies provide are: performing audits; performing actuarial analysis; adjudication and payment of claims; customer service support; utilization review and management; coordination of benefits; subrogation; pharmacy benefit management; and technological functions. TRS may disclose your protected health information to its business associates so that they can perform the services that TRS has asked them to do. To protect your health information, however, TRS requires that these companies follow the same rules that are set out in this notice and to notify TRS in the event of a breach of your unsecured protected health information.
• For health care operations. TRS may use or disclose your protected health information to support health plan administration functions. TRS may provide your protected health information to its accountants, attorneys, consultants and others in order to make sure TRS is complying with the laws that affect it. For example, your protected health information may be given to people looking at the quality of the health care you received. Another example of health care operations is TRS using and sharing this information to manage its business and perform its administrative activities.
23
Important Notices
• Executor or administrator. TRS may disclose your protected health information to the executor or administrator of your estate.
Certain disclosures that TRS is required to make. The following is a description of disclosures that TRS is required by law to make:
• Health-related benefits. TRS or one of its business associates may contact you to provide appointment reminders. They may also contact you to give you information about treatment alternatives or other health benefits or services that may be of interest to you.
• Disclosures to the Secretary of the U.S. Department of Health and Human Services. TRS is required to disclose your protected health information to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA Privacy Regulations.
• Legal proceedings. TRS may disclose your protected health information: (1) in the course of any judicial or administrative proceeding, including, but not limited to, an appeal of denial of coverage or benefits; (2) in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized by law); and (3) because it is necessary to provide evidence of a crime that occurred on our premises.
• Disclosures to you. TRS is required to disclose to you most of your protected health information in a “designated record set” when you request access to this information, including information maintained electronically. Generally, a “designated record set” contains medical and billing records, as well as other records that are used to make decisions about your health care benefits. TRS is also required to provide, upon your request, an accounting of the disclosures of your protected health information. In many cases, your protected health information will be in the possession of a plan administrator or pharmacy benefits manager. If you request protected health information, TRS will work with the administrator or pharmacy benefits manager to provide your protected health information to you.
• Coroners, medical examiners, funeral directors and organ donation. TRS may disclose protected health information to a coroner or medical examiner for purposes of identifying a deceased person, determining a cause of death, or for the coroner or medical examiner to perform other duties authorized by law. TRS also may disclose, as authorized by law, protected health information to funeral directors so that they may carry out their duties. Further, TRS may disclose protected health information to organizations that handle organ, eye, or tissue donation and transplantation.
Certain uses and disclosures of genetic information that cannot be made. TRS and Medical Board members, auditors, actuarial consultants, lawyers, health plan administrators or pharmacy benefit managers acting on behalf of TRS, TRS-Care or TRS-ActiveCare are prohibited from using or disclosing genetic information for underwriting purposes.
• Research. TRS may disclose your protected health information to researchers when an institutional review board or privacy board has: (1) reviewed the research proposal and established protocols to ensure the privacy of the information; and (2) approved the research.
Certain uses and disclosures of protected health information that will not be made. The following uses and disclosures of protected health information will not be made by TRS and Medical Board members, auditors, actuarial consultants, lawyers, health plan administrators or pharmacy benefit managers acting on behalf of TRS, TRS-Care or TRS-ActiveCare:
• To prevent a serious threat to health or safety. Consistent with applicable federal and state laws, TRS may disclose your protected health information if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
• Uses and disclosures that constitute marketing purposes;
• Inmates. If you are an inmate of a correctional institution, TRS may disclose your protected health information to the correctional institution or to a law enforcement official for: (1) the institution to provide health care to you; (2) your health and safety and the health and safety of others; or (3) the safety and security of the correctional institution.
• Uses and disclosures that constitute the sale of your protected health information; and • Uses and disclosures that constitute fundraising purposes.
• Workers’ compensation. TRS may disclose your protected health information to comply with workers’ compensation laws and other similar programs that provide benefits for work-related injuries or illnesses.
All other uses and disclosures require your prior written authorization. The following uses and disclosures will be made by TRS and Medical Board members, auditors, actuarial consultants, lawyers, health plan administrators or pharmacy benefit managers acting on behalf of TRS, TRS-Care or TRS-ActiveCare only with a written permission (an authorization) from you:
• To your personal representative. TRS may provide your protected health information to a person representing or authorized by you, or any person that you tell TRS in writing is acting on your behalf. For this purpose, a person acts on your behalf by being involved in your health care or in the payment for your health care.
• Most uses and disclosures of psychotherapy notes; and • For any other use or disclosure of your protected health information that is not described in this notice.
• To an entity assisting in disaster relief. TRS may also disclose your protected health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. If you are not present or able to agree to these disclosures of your protected health information, then TRS may, using our professional judgment, determine whether the disclosure is in your best interest. TRS will attempt to gain your personal authorization when possible before making such disclosures.
If you provide TRS with such an authorization, you may cancel (revoke) the authorization in writing at any time, and this revocation will be effective for future uses and disclosures of your protected health information. Revoking your written permission will not affect a use or disclosure of your protected health information that TRS and Medical Board members, auditors, actuarial consultants, lawyers, health plan administrators or pharmacy benefit managers acting on behalf of TRS, TRS-Care or TRS-ActiveCare already made, based on your written authorization.
24
Important Notices
Your Rights
If you request copies of your protected health information, TRS can charge you a fee for each page copied, for the labor involved in compiling and copying the information, and for postage if you request that the copies be mailed to you. Instead of providing the protected health information you request, TRS may provide you with a summary or explanation of the information, but only if you agree in advance to:
The following is a description of your rights with respect to your protected health information: • The right to request limits on uses and disclosures of your protected health information. You can ask that TRS limit how it uses and discloses your protected health information. TRS will consider your request but is not required to agree to it. If TRS agrees to your request, TRS will put the agreement in writing and will follow the agreement unless you need emergency treatment, and the information that you asked to be limited is needed for your emergency treatment. You cannot limit the uses and disclosures that TRS is legally required to make.
Receive a summary or explanation instead of the detailed protected
health information; and
Pay the cost of preparing the summary or explanation.
The fee for the summary or explanation will be in addition to any copying, labor, and postage fees that TRS may require. If the total fees will exceed $40, TRS will tell you in advance. You can withdraw or change your request at any time.
If you are enrolled in TRS-ActiveCare, you may request a restriction by writing to: Aetna Legal Support Services, 152 Farmington Avenue, W121, Hartford, CT 06156-9998. In your request, state: (1) the information whose disclosure you want to limit, and (2) how you want to limit our use and/or disclosure of the information.
TRS may deny your request to inspect and copy your protected health information in certain limited circumstances. If you are denied access to your protected health information, you may request that the denial be reviewed. TRS will choose a licensed health care professional to review your request and the denial. The person performing this review will not be the same one who denied your initial request. Under certain conditions, the denial will not be reviewable. If this event occurs, TRS will inform you in our denial that the decision is not reviewable.
If you are enrolled in TRS-Care, you may request a restriction by writing to: Aetna Legal Support Services, 152 Farmington Avenue, W121, Hartford, CT 06156-9998. In your request, state: (1) the information whose disclosure you want to limit, and (2) how you want to limit our use and/or disclosure of the information.
• The right to get a list of TRS’ uses and disclosures of your protected health information. You have the right to get a list of TRS’ uses and disclosures of your protected health information. By law, TRS is not required to create a list that includes any uses or disclosures:
You have the right to request that your protected health information not be disclosed to TRS if you have paid for the service received in full. • The right to choose how TRS sends protected health Information to you. You can ask that TRS send information to you to an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, courier service instead of U.S. mail) only if not changing the address or the way TRS communicates with you could put you in physical danger. You must make this request in writing. You must be specific about where and how to contact you. TRS must agree to your request only if:
To carry out treatment, payment or healthcare operations;
To you or your personal representative;
Because you gave your permission;
For national security or intelligence purposes;
To corrections or law enforcement personnel; or
Made prior to three (3) years before the date of your request, but in
You clearly tell TRS that sending the information to your usual address
no event made before April 14, 2003.
or in the usual way could put you in physical danger; and
TRS will respond to your request within 60 days of receiving it. TRS can extend this deadline one time by an additional 30 days. If TRS extends its response time, TRS will tell you in writing the reasons for the delay and the date by which TRS will provide the list. The list will include:
You tell TRS a specific alternative address or specific alternative means of
sending protected health information to you. If you ask TRS to contact you via an email address, TRS will not send protected health information by email unless it is possible for the protected health information to be encrypted.
The date of the disclosure or use;
• The right to see and get copies of your protected health information. You can look at or get copies of your protected health information that TRS has or that a business associate maintains on TRS’ behalf. You must make this request in writing. If your protected health information is not on file at TRS and TRS knows where the information is maintained, TRS will tell you where you can ask to see and get copies of your information. You may not inspect or copy psychotherapy notes or certain other information that may be contained in a designated record set that is in the possession of TRS or a business associate of TRS.
The person or entity that received the protected health information;
A brief description of the information disclosed; and
Why TRS disclosed or used the information.
If TRS disclosed your protected health information because you gave TRS written permission to disclose the information, instead of telling you why TRS disclosed the information, TRS will give you a copy of your written permission. You can get a list of disclosures for free every 12 months. If you request more than one list during a 12-month period, TRS can charge you for preparing the list, including charges for copying, labor, and postage to process and mail each additional list. These fees will be the same as the fees allowed under the Texas Public Information Act. TRS will tell you in advance of the fees it will charge. You can withdraw or change your request at any time.
25
Important Notices
• The right to get this notice. You can get a paper copy of this notice on request.
• The right to correct or update your protected health information. If you believe that there is a mistake in your protected health information or that a piece of important health information is missing, you can ask TRS to correct or add the information. You must request the correction or addition in writing.
• The right to file a complaint. If you think that TRS has violated your privacy rights concerning your protected health information, you can file a written complaint with the TRS Privacy Officer by mailing your complaint to:
Your letter must tell TRS what you think is wrong and why you think it is wrong. TRS will respond to your request within 60 days of receiving it. TRS can extend this deadline one time by an additional 30 days. If TRS extends its response time, it must tell you in writing the reasons for the delay and the date by which TRS will respond.
Because of the technology used to store information and laws requiring TRS to retain information in its original text, TRS may not be able to change or delete information, even if it is incorrect. If TRS decides that it should correct or add information, it will add the correct or additional information to your records and note that the new information takes the place of the old information. The old information may remain in your record. TRS will tell you that the information has been added or corrected. TRS will also tell its business associates that need to know about the change to your protected health information.
Privacy Officer Teacher Retirement System of Texas 1000 Red River Street Austin, Texas 78701
All complaints must be in writing. You may also send a written complaint to: Region VI, Office for Civil Rights Secretary of the U.S. Department of Health and Human Services 1301 Young Street, Suite 1169 Dallas, Texas 75202 Fax: 214-767-0432, and email at
[email protected] Complaints filed directly with the Secretary must: (1) be in writing; (2) contain the name of the entity against which the complaint is lodged; (3) describe the relevant problems; and (4) be filed within 180 days of the time you became or should have become aware of the problem.
TRS will deny your request if your request is not in writing or does not have a reason why the information is wrong or incomplete. TRS will also deny your request if the protected health information is: • Correct and complete;
Finally, you may send a written complaint to:
• Not created by TRS; or
Texas Office of the Attorney General P.O. Box 12548 Austin, Texas, 78711-2548 1-800-806-2092
• Not part of TRS’ records. TRS will send you the denial in writing. The denial will say why your request was denied and explain your right to send TRS a written statement of why you disagree with TRS’ denial. TRS’ denial will also tell you how to complain to TRS or the Secretary of the Department of Health and Human Services. If you send TRS a written statement of why you disagree with the denial, TRS can file a written reply to your statement. TRS will give you a copy of any reply.
TRS will not penalize or in any other way retaliate against you if you file a complaint. More Information If you want more information about this notice, how to exercise your rights or how to file a complaint, please contact the TRS Telephone Counseling Center at 1-800-223-8778. TDD users should call 1-800-841-4497.
If you file a written statement disagreeing with the denial, TRS must include your request for an amendment, the denial, your written statement of disagreement, and any reply when TRS discloses the protected health information that you asked to be changed; or TRS can choose to give out a summary of that information with a disclosure of the protected health information that you asked to be changed. Even if you do not send TRS a written statement explaining why you disagree with the denial, you can ask that your request and TRS’ denial be attached to all future disclosures of the protected health information that you wanted changed. • The right to be notified of a breach of unsecured Protected Health Information. You have the right to be notified and TRS has the duty to notify you of a breach of your unsecured protected health information. A breach means the acquisition, access, use or disclosure of your unsecured protected health information in a manner not permitted under HIPAA that compromises the security or privacy of your protected health information. If this occurs, you will be provided information about the breach and how you can mitigate any harm as a result of the breach.
26
Enrollment Application and Change Form
ELIGIBILTY:
Are you an active employee and making monthly contributions to TRS? ☐ Yes If no, are you regularly scheduled to work 10 or more hours per week? ☐ Yes
(If no to both, you are not eligible for TRS-ActiveCare coverage)
☐ No ☐ No
SECTION 1: ENROLLMENT/CHANGE TRANSACTION TYPE
□ Annual Enrollment
☐ New Employee
☐ Add Dependent
For District Use Only
☐ Special Enrollment
□ For New Employee (check one):☐Effective on Actively at Work ☐Effective 1st day of month following ☐Court Order
☐Marriage
☐Birth/Adoption
AmyHuman Freeman, Human Resources at 512-706-7564 Amy/ Freeman, Resources at 512-706-7564 Amy/ Freeman, Human Resources at 512-706-7564 Special Enrollment Event Date: ___ ___ ___ ☐ Loss of Coverage ☐Other: Change Only: Decline Coverage: Cancel Employee Cancel Dependent ☐Yes (Complete Section 6) ☐Divorce ☐Death ☐ Name ☐N/A ☐Death ☐Loss of Eligibility ☐Retirement/Terminated ☐Loss of Eligibility Effective Date of Change/Cancel ☐Address ☐Non-Payment ☐Dropped Coverage ☐Plan/Coverage _____ / _____ / _________ ☐Other: _____________ ☐Other: ____________
TRS District # Actively at Work Date: Effective/Change Date: Employer Approval:
Were you covered by another district? ☐ Yes ☐ No If so, which: _______________
SECTION 2: EMPLOYEE INFORMATION Last Name:
First Name:
Mailing Address: Home Phone Number: Date of Birth:
MI:
Social Security #:
City:
State: Email:
Cell Phone Number: Sex: ☐M ☐F
Language: ☐ English
Zip:
Ethnicity:
☐Spanish
Do you have a disability affecting your ability to communicate or read? ☐Yes (Please complete Section 8) Is the Employee Covered By Other Insurance? ☐Yes Carrier/Plan: Is the Employee Covered by Medicare? ☐Yes ☐Part A ☐Part B ☐Part C ☐Part D Effective:
☐ No ☐No ☐No
Reason for Medicare Coverage: ☐ Entitlement Age ☐ Disability ☐End Stage Renal Disease (ESRD) SECTION 3: COVERAGE SELECTION (Please select a Plan of Coverage and Coverage Type) PPO Selection: ☐ActiveCare 1-HD ☐ActiveCare Select ☐ActiveCare 2 HMO Selection: ☐FirstCare ☐Scott & White Health Plan ☐Valley Baptist Health Plan Coverage Type Selected: ☐Employee Only ☐Employee + Spouse ☐Employee + Child(ren) ☐Employee + Family SECTION 4: DEPENDENT INFORMATION (Use additional form for additional dependents) SPOUSE Last Name: Street Address: Amy Freeman, Human Resources City: State: Sex: ☐M ☐F
Date of Birth:
First Name: Zip:
Phone Number: Social Security #:
Other Insurance: ☐Yes. Carrier/Plan CHILD Last Name:
☐No ☐Medicare: ☐Part A First Name:
☐Natural/Adopted ☐Stepchild ☐Foster Child Street Address: 512-706-7564 City: State: Social Security #: Date of Birth: Other Insurance: ☐Yes. Carrier/Plan CHILD Last Name:
☐Grandchild
Social Security #: Date of Birth: Other Insurance: ☐Yes. Carrier/Plan
State:
☐Legal Guardian
☐Part B ☐Disabled
☐Part C
☐Part D MI:
☐ Other ☐Same as Employee
Zip Code:
Phone Number: Sex: ☐M ☐F ☐No ☐Medicare: ☐Part A ☐Part B ☐Part C First Name:
☐Natural/Adopted ☐Stepchild ☐Foster Child ☐Grandchild
[email protected] Street Address: City:
MI: ☐Same as Employee
Zip Code:
☐Legal Guardian
☐Disabled
☐Part D MI:
☐ Other ☐Same as Employee
Phone Number:
Sex: ☐M ☐F ☐No ☐Medicare: ☐Part A ☐Part B ☐Part C PLEASE CONTINUE ON NEXT PAGE
☐Part D
CHILD Last Name: ☐Natural/Adopted
First Name: ☐Stepchild
☐Foster Child
☐Legal Guardian
☐Grandchild
Street Address: 8305 Cross Park Drive, Austin, TX 78754 City: State: Date of Birth:
MI: ☐Same as Employee Zip Code:
Phone Number:
Social Security #:
Other Insurance: ☐Yes. Carrier/Plan CHILD Last Name: ☐Natural/Adopted ☐Stepchild
Sex: ☐M ☐F ☐Medicare: ☐Part A
☐No
First Name: ☐Foster Child ☐Grandchild
Street Address: City: Date of Birth:
☐ Other
☐Disabled
☐Part B ☐Part C ☐Part D MI: ☐Legal Guardian ☐Disabled ☐ Other ☐Same as Employee
State: Social Security #: Other Insurance: ☐Yes. Carrier/Plan SECTION 5: DISABLED DEPENDENTS OVER AGE 26
Zip Code: ☐No
Phone Number: Sex: ☐M ☐F:
☐Medicare: ☐Part A ☐Part B ☐Part C ☐Part D ☐ Dependent Child’s Statement of Disability Attached
Please note that a Dependent Child’s Statement of Disability form is required for coverage of a disabled child over age 26. See your Benefits Administrator for the form, which must be completed in full and submitted to your Benefits Administrator.
SECTION 6: DECLINATION OF COVERAGE This is to certify that the available coverage has been explained to me. I have been given the opportunity to apply for the coverage available to me and my dependents and have voluntarily elected to decline the coverage as elected below.
Name:
☐Employee
Reason:
☐Other Coverage
☐Other:
Name:
SSN:
☐Spouse
Reason:
☐Other Coverage
☐Other:
Name: Name:
☐Child ☐Child
Reason: Reason:
☐Other Coverage ☐Other Coverage
☐Other: ☐Other:
Name: Name:
☐Child ☐Child
Reason: Reason:
☐Other Coverage ☐Other Coverage
☐Other: ☐Other:
SECTION 7: COVERAGE CONDITIONS • I am employed by the Employer named in this Enrollment Application and Change Form. I am eligible to participate in the coverage(s) offered by the
• • • • •
TRS-ActiveCare program which is administered by Aetna, with HMO benefits provided by SHA, L.L.C. dba FirstCare, Scott and White Health Plan, and Valley Baptist Insurance - Company dba Valley Baptist Health Plans. On behalf of myself and any dependents listed on their Enrollment Application and Change Form, I apply for those coverage(s) for which I am eligible. o If I am enrolling a grandchild in Section 4, I certify that my household is the grandchild’s primary residence and the grandchild is my dependent for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect. o If I am enrolling a child as an “other Child” in Section 4, I certify that my household is the child’s primary residence, that I provide at least 50% of the child support, that neither of the children’s natural parents reside in my household, and that I have the legal right to make decisions regarding the child’s medical care. Only those coverage(s) and amount for which I am eligible will be available to me. I understand that if this Enrollment Application and Change Form is accepted, the coverage(s) will become effective in accordance with the provisions or the TRS-ActiveCare program. I understand that by enrolling for coverage with Employer named in the Enrollment Application and Change Form that any TRS-ActiveCare coverage I previously elected under another TRS-ActiveCare participating district/entity will be terminated under TRS Rules. I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). I agree that my Employer acts as my agent. All notices given to my Employer are binding upon me. I also agree that my participation in the coverage(s) is subject to any future amendments. I understand that by declining TRS-ActiveCare coverage now or by terminating TRS-ActiveCare coverage during the plan year, I am not eligible to re-enroll in TRS-ActiveCare until the next plan year, unless I experience a special enrollment event. I state that the information given on the Enrollment Application and Change Form is true and correct. I understand and agree that any incorrect statements material to the risk and knowingly made by me will invalidate my coverage(s).
Applicant Signature: __________________________________________________________________ Date: ________________________ SECTION 8: SPECIAL NOTES REGARDING MY ENROLLMENT (Please indicate any special information regarding my enrollment for Aetna, Caremark or
my selected HMO)
•
TRS AcƟveCare
•
Telehealth & Health Advocacy
•
Dental
•
Vision
•
Disability
•
Term Life
•
Permanent Life
•
Accident
•
Cancer
•
Supplemental Medical
•
CriƟcal Illness
IMPORTANT INFORMATION Trinity Charter School is pleased to offer our employees a wide variety of benefits to suit your needs. The informa on found within this book is designed to assist you in making important decisions regarding your benefits and provide you with important contact informa on. Combined Benefits Group, Inc. (CBG) is the Third Party Administrator for the School’s Supplemental Benefit Plans.
Annual Enrollment The Annual Enrollment is your opportunity to review your current benefits and make changes for the upcoming plan year.
Plan Enrollment Periods The annual enrollment will take place from August 1st through August 31st. During this period Representa ves from Combined Benefits Group will be made available on campus to answer any ques ons you may have and assist you with your enrollment.
Plan Year The Plan Year for the Hu o ISD’s Benefit Plans is 9/1/2014 - 8/31/2015.
New Hire Enrollment New employees have 31 days from your date of employment to enroll in benefits. Benefits will then become effec ve the first of the month following your date of hire. Failure to complete your elec ons during this me period will result in the forfeiture of coverage.
Mid Year Changes Once enrolled in the Cafeteria Plan, mid-year changes can only be made based on an approved IRS Qualifying Event. Employees have 31 days a er a qualifying event to make changes based on that event. It is the responsibility of the employee to noƟfy your employer of such changes and to complete the proper paperwork. Any changes to benefits must be consistent with the IRS approved qualifying event.
IRS Approved Qualifying Events IRS approved Qualifying Events include, but are not limited to: Change in Marital Status, Birth or Adop on of a Child, Death of a Dependent, Change of Employee’s or Spouse’s Employment, En tlement to Medicare or Medicaid, FMLA, Leave of Absence and COBRA Qualifying Events. Should you have any ques ons regarding your certain circumstances, Please contact the Human Resources Department or CBG, Hu o ISD’s Third Party Administrator for approval of any qualifying event.
Frequently Asked QuesƟons Who Do I contact with QuesƟons? For supplemental benefit ques ons, you can contact the Human Resources Department or you can call Combined Benefits Group at 800-749-6458 for assistance. Where can I find forms and Provider Networks? For benefit summaries, claim forms and links to provider networks, go to our school district’s employee benefit portal by visi ng www.mybenefitshub.com/trinitycharterschools. Click on the benefit plan you need informa on on (i.e. Dental) and you can find the forms and links you need. When will I receive ID Cards? If the insurance company provides ID Cards, you can expect to receive them 2 - 3 weeks a er your effec ve date. For most dental and vision plans you can login to the company’s website and print a temporary ID Card or simply give your provider the insurance company’s name and phone number and they can verify coverage. What if I Need Help CompleƟng my Enrollment? You can visit with the representa ve from Combined Benefits Group while they are on campus. Enrollment Assistance is also available by calling Combined Benefits Group at 800-749-6458 to speak with a licensed representa ve, Monday—Friday, 8am— 5pm CST.
CONTACT INFORMATION We are dedicated to serving your needs and are available to assist you with your claim issues and benefit ques ons. Please follow the steps below to help expedite this process. 1) The majority of issues or ques ons can be resolved or answered with a phone call to your insurance carrier. However, we do understand that insurance can be complicated; therefore, 2) If you contact your insurance carrier and your issue or ques on is not resolved or answered, please allow Combined Benefits Group to assist you by contac ng one of their dedicated service professionals. 3) If your issue or ques on is s ll not resolved or answered, please contact your Human Resources Department.
Provider
Phone Number
Website
Page
Combined Benefits Group
800-749-6458
mybenefitshub.com/ trinitycharterschools
1-2
Aetna
800-222-9205
www.trsac vecareaetna.com
3-4
ScoƩ & White HMO
800-321-7947
h ps://trs.swhp.org
Access Medical
800-800-7616
www.accessmedcard.com
5-6
American Public Life
800-256-8606
www.ampublic.com
7 - 10
Dental
Assurant Employee Benefits
866-376-9478
www.assurantemployeebenefits .com
11 - 20
Vision
Block Vision
866-265-0517
www.blockvision.com
21 - 23
Disability
Unum
866-679-3054
www.unum.com
24 - 32
Term Life & AD&D
Unum
866-679-3054
www.unum.com
33 - 38
Texas Life
800-283-9233
www.texaslife.com
39 - 42
Cancer
American Public Life
800-256-8606
www.ampublic.com
43 - 46
Accident
American Public Life
800-256-8606
www.ampublic.com
47 - 48
Sun Life
800-247-6875
www.sunlife.com
49 - 52
Benefit Plan Enrollment InstrucƟons TRS AcƟveCare
Telehealth & Health Advocacy Medical Gap Plan
Permanent Life
CriƟcal Illness
AddiƟonal Benefit InformaƟon Trinity Charter School’s Employee Benefit Portal Benefit InformaƟon
|
Online Enrollment Access
|
Contact InformaƟon
| Claim Forms
www.mybenefitshub.com/trinitycharterschools
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HUB-1.3 (06/2014)
2
Welcome
Enrollment Period: July 21–August 31
Choosing a plan option Welcome to 2014-2015 Plan Enrollment
ActiveCare 3 to be discontinued
Enroll now! During the plan enrollment period, you may select a plan option, make plan changes and add or delete dependents from your health coverage without a special enrollment event.
Effective September 1, 2014, ActiveCare 3 will be discontinued as a plan option. If you are currently enrolled in ActiveCare 3, you will be automatically enrolled in ActiveCare 2 unless you make a different plan selection by September 1, 2014.
This guide provides an overview of what is new for the 2014-2015 plan year, descriptions of the available plan options, a list of important reminders and actions required for enrollment and participation in the TRS-ActiveCare health plans, as well as certain notifications about your health benefits. Additional information about your options for coverage is available to you online at www.trs.state.tx.us/trsactivecare or you can call TRS-ActiveCare Customer Service at 1-800-222-9205 and speak to an Aetna Health Concierge.
New plan – ActiveCare Select ActiveCare Select is a new plan option under TRS-ActiveCare that is designed to meet the essential health benefits required of all health plans, while limiting less frequently used benefits and services. Be sure to check out this new plan’s benefits and limitations in the Benefits Summaries and Plan Comparisons section of this Enrollment Guide.
New ID cards for plan members
9OU SHOULD CHOOSE YOUR PLAN CAREFULLY 9OU MAY NOT CHANGE PLANS DURING A PLAN year unless you experience a qualified special enrollment event. There may be restrictions to making plan changes in future plan years as well.
Aetna If you enroll in one of the TRS-ActiveCare plan options (i.e., not an HMO), you will RECEIVE A NEW !ETNA MEMBER )$ CARD IN THE MAIL 9OU WILL RECEIVE THE NEW CARD even if you are staying in the same TRS-ActiveCare plan option, because your plan will now be administered by Aetna.
What's new
The cards are family ID cards – which means up to five covered family members will be listed on the card. If you have more than four dependents, you will receive an additional card displaying your other dependents. If you need more ID cards, call TRS-ActiveCare Customer Service at 1-800-222-9205 and speak to an !ETNA (EALTH #ONCIERGE 9OU ALSO MAY REQUEST ADDITIONAL CARDS OR REPLACEMENTS FOR LOST CARDS BY LOGGING IN TO YOUR SECURE MEMBER WEBSITE !ETNA .AVIGATOR ® at www.trsactivecareaetna.com 9OU WILL NEED TO BE REGISTERED WITH !ETNA .AVIGATOR TO USE ITS FEATURES AND TOOLS 4URN TO PAGE TO LEARN MORE
Aetna and Caremark will be the new plan administrators Effective September 1, 2014, Aetna will replace Blue Cross and Blue Shield ® of Texas as the administrator of the ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans. Caremark will replace Express Scripts® as the administrator of our prescription drug benefits. About Aetna Aetna is one of America’s most experienced and progressive health insurance companies. Choosing Aetna to administer TRS-ActiveCare plans means you and your family can enjoy the advantages of:
Caremark 9OUR PRESCRIPTION BENElT PLAN IS DESIGNED TO BRING YOU QUALITY PHARMACY CARE that will help you save money. If you enroll in one of the TRS-ActiveCare plan options, you will receive a new Caremark prescription drug ID card in the mail. 9OU WILL RECEIVE THE NEW CARD EVEN IF YOU ARE STAYING IN THE SAME 423 !CTIVE#ARE plan option. Included with the ID card will be Caremark Welcome Kit reflecting your elected prescription benefit plan. If you need to obtain a temporary ID card or order additional cards, you can call 1-800-222-9205 and select option #2 to speak to a Caremark representative, or you can go online at www.caremark.com/trsactivecare.
s One of America’s largest provider networks s One-on-one support from nurse consultants and other health professionals to help you reach your wellness goals s A Health Concierge available by phone for answers and guidance on care and benefits s Online services and mobile apps for easy access to health information and tools for those who travel
Be sure to take your prescription ID card to your pharmacy when you get a PRESCRIPTION lLLED FOR THE lRST TIME 9OUR 423 !CTIVE#ARE MEMBER NUMBER IS the same on both your Aetna medical card and your Caremark prescription benefit card, so you may present either card to your pharmacy when you fill a prescription for medications.
s Enhanced customer service that helps you better understand and use Aetna benefits, programs and tools, and much more To get the best view of Aetna resources available to you, visit www.trsactivecareaetna.com for plan and benefit information. About Caremark Caremark is the largest pharmacy health care provider in the United States. Caremark’s network includes more than 64,000 pharmacies nationwide, including chain pharmacies and 20,000 independent pharmacies.
ID card distribution If you change your plan election after August 11, 2014, you will receive a second set of ID cards in the mail from Aetna and Caremark. The new cards will reflect your updated plan information. Please destroy all old ID cards when you receive your replacement cards. Please note: If prior or to receiving your second set of Caremark ID cards, you need to fill a prescription prescription beginning September 1, you can use your original Caremark card. c
Through Caremark pharmacy services, you can order maintenance and specialty medications online or by phone, and have them delivered directly to you. The Caremark website offers these and other services, including Ask-a-Pharmacist, for answers and information about your medications. To start using these and other features and services, register at www.caremark.com/trsactivecare.
1
3
AcveCare 1-HD Aetna PPO
AcveCare 2 Aetna PPO
AcveCare Select
Sco & White HMO
First Care HMO
Deducble (per plan year)
$2,500 Employee $1,000 Employee $1,200 Employee $1,000 Employee $5,000 Family $3,000 Family $3,600 Family $3,000 Family
Out-of-Pocket Maximum (per plan year; includes Deducble/Copays/Coinsurance)
$6,350 Employee $6,000 Employee $6,350 Employee $4,000 Employee $4,450 Employee $9,200 Family $12,000 Family $9,200 Family $9,000 Family $9,125 Family
Coinsurance (Plan Pays / Parcipant Pays)
$450 Employee $1,125 Family
80% / 20%
80% / 20%
80% / 20%
80% / 20%
75% / 25%
Oce Visit (Parcipant Pays)
20% Aer Deducble
$30 Primary $50 Specialist
$30 Primary $60 Specialist
$20 Primary $50 Specialist
$20 Primary $60 Specialist
Preventave Care
Plan Pays 100%
Plan Pays 100%
Plan Pays 100%
Plan Pays 100%
Plan Pays 100%
$40 Consultaon Fee
Plan Pays 100%
Plan Pays 100%
Not Available
Not Available
Teladoc Physician Services
High-tech Radiology - CT Scan, MRI, nuclear medicine (Parcipant Pays)
20% Aer Deducble
$100 Copay, plus $100 Copay, plus 20% aer 20% aer deducble deducble
20% Aer Deducble
25% Aer Deducble
20% Aer Deducble
$150 Copay per day, plus 20% aer deducble
$150 Copay per day, plus 20% aer deducble
25% Aer Deducble
20% Aer Deducble
$150 Copay, plus $150 Copay, plus $150 Copay, plus 20% aer 20% aer 20% aer deducble deducble deducble
25% Aer Deducble
20% Aer Deducble
$150 Copay per visit, plus 20% aer deducble
$150 Copay per visit, plus 20% aer deducble
$150 Copay per visit, plus 20% aer deducble
25% Aer Deducble
Subject to Plan Year Deducble
$0 for generic, $200 per person for brand name
$0 for generic, $200 per person for brand name
$0 for generic, $100 per person for brand name
$100 per person $300 per family
Retail Short-Term (up to 31-day supply) Generic Brand (preferred list) Brand (non-preferred list)
Parcipant pays 20% aer deducble
Parcipant Pays $20 $40 $65
Parcipant Pays $20 $40 50%
Parcipant Pays $3 30% 50%
Parcipant Pays $10 $30 $60
Retail Maintenance (aer 2nd ll) Generic Brand (preferred list) Brand (non-preferred list)
Parcipant pays 20% aer deducble
Parcipant Pays $25 $50 $80
Parcipant Pays $25 $50 50%
Parcipant Pays $6 30% 50%
Parcipant Pays $30 $90 $180
Inpaent Hospital - Facility charges (Parcipant Pays) Emergency Room (Parcipant Pays) Outpaent Surgery (Parcipant Pays) Prescripon Drugs Drug Deducble (per plan year)
$150 Copay per day, plus 20% aer deducble
Total Monthly Premiums (Excludes Your Employer Contribuon) Employee Only
$325
$555
$450
$452.80
$390.14
Employee & Spouse
$850
$1,287
$1,044
$1,020.08
$977.76
Employee & Child(ren)
$572
$875
$709
$717.32
$618.94
$1,145
$1,323
$1,238
$1,131.50
$987.44
Employee & Family
4
24 / 7 call a doctor service, health advocacy, wellness support & prescription discounts
all in one easy to use card Telehealth, Health Advocacy, Medical Bill SaverTM, NurselineTM, Online Wellness, Diabec Management & Discount Pharmacy
The Access Medical card can save busy families hundreds to thousands of dollars on healthcare costs. Choose the plan that is perfect for your family
Access Medical
Access Medical Plus
Teladoc
Included
Included
Medical Health Advisor
Included
Included
Medical Bill SaverTM
Included
Included
NurselineTM
Included
Included
Discount Pharmacy
Included
Included
Online Wellness
Included
Included
Diabec Management
Included
Included
Legal Care Direct
Included
Safe Identy
Included
Employee Cost (per month per family)
Employer Paid
$12.50
Disclosures. This plan is NOT insurance. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Aordable Care Act. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organizaon. This discount card program contains a 30 day cancellaon period. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received. Member shall receive a full refund of membership fees, excluding registraon fee, if membership is cancelled within the rst 30 days aer the eecve date. Discount Medical Plan Organizaon: New Benets, Ltd., An: Compliance Department, PO Box 671309, Dallas, TX 75367-1309, 800-800-7616. Website to obtain parcipang providers: MyMemberPortal.com. Available only to TX, NM and FL residents. 5 AMBC2HS - A REV JUNE2014
Teladoc
Feel beer now! 24/7 access to a doctor is only a call away—anyme, anywhere with no consultaon fee. With Teladoc, you can talk to a doctor by phone consult to get a diagnosis, treatment opons and prescripon if necessary. Save me and money by avoiding crowded waing rooms in the doctor’s oce, urgent care clinic or ER. Just use your phone, to get a quick diagnosis by a U.S. licensed physician.
Medical Health Advisor
Healthcare is becoming harder to understand. Personal Health Advocates help you nd your way through insurance and healthcare systems. They can also locate doctors, specialists, hospitals, densts and pharmacies. Advocates research treatments, resolve claims and provide medical explanaons so you can make more informed decisions.
Medical Bill SaverTM
Major issues can add up to major bills! Call Medical Bill Saver™ and rest easy. Experts who know the ins and outs of billing pracces will negoate with providers to help you save. Negoators can oen save you 25% to 50% on uncovered medical and dental bills over $400. You’ll receive an easy-to-read Savings Results Statement with negoated payment terms.
NurselineTM
You’re in good hands. You and your family have a place to turn to for trusted advice and informaon when you need it most. Rest assured—highly trained registered nurses are on-call 24/7 to answer your quesons. Whether your baby has a fever in the middle of the night, you think you have the u or you TM need to discuss side eects of medicaons, call Nurseline .
Discount Pharmacy
Don’t pay full price! Save 10% to 85% on most prescripons at over 60,000 pharmacies. Just present your card to save an average of 42% at locaons naonwide. Compare your prescripon prices and see for yourself at RxPriceQuotes.com.
Online Wellness
Get your t on! Get stronger, lose weight and feel beer with the tools you need to make wellness part of your daily life. You’ll enjoy personal workouts, health ps, thousands of arcles and more.
Diabec Management
Diabetes can be hard to manage–an average savings of 48% on supplies and the convenience of right-to-the-door service can make life easier. Comprehensive support and personalized care plans make it easier to manage diabetes and reduce the number of medical visits.
Legal Care Direct
Have legal quesons? Get legal answers from experienced lawyers at discounted rates. Aorneys help with trac ckets, bankruptcy, divorce, and spousal and child support. Addional services are also available at no cost to you!
Safe Identy
Stay one step ahead of identy the. If you are online, have a bank account or use a credit card, your personal informaon can be stolen at any me. Be protected and alerted if any suspicious or unusual acvity is found.
Disclosures: This plan is NOT insurance. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Aordable Care Act. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organizaon. This discount card program contains a 30 day cancellaon period. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received. Member shall receive a full refund of membership fees, excluding registraon fee, if membership is cancelled within the rst 30 days aer the eecve date. Discount Medical Plan Organizaon: New Benets, Ltd., An: Compliance Department, PO Box 671309, Dallas, TX 75367-1309, 800-800-7616. Website to obtain parcipang providers: MyMemberPortal.com. Available only to TX, NM and FL residents. © 2014 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without wrien permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescripon will be wrien. Teladoc operates subject to state regulaon and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeuc drugs and certain other drugs which may be harmful because of their potenal for abuse. Teladoc physicians reserve the right to deny care for potenal misuse of services. Teladoc phone consultaons are available 24 hours, 7 days a week while video consultaons are available during the hours of 7am to 9pm, 7 days a week. AMBC2HS - A REV JUNE2014
6
MedLink III - Supplemental Limited Benefit Medical Expense Insurance
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Today Protect Tomorrow To
American Public Life’s MedLink III Supplemental Limited Benet Medical Expense Insurance is designed to work in conjuncon with your Medical Plans to help oset the outofpocket costs that you may experience due to the deducbles and coinsurance for InPaent Hospital Charges
How does this plan work with my medical coverage? InNetwork Benets Deducble1 (Per Plan Year; Individual) CoInsurance2 OutofPocket Maximum3 (Per PlanYear; Individual)
AcveCare IHD
AcveCare II
Select
Sco & White
$2,500
$1,000
$1,200
$1,000
20%
20%
20%
20%
$6,350
$6,000
$6,350
$4,000
up to $4,000
up to $4,000
Up to $4,000
up to $4,000
Med Link III Gap Plan In Hospital Benet
1. 2. 3.
Deducble is the set amount of out of pocket expenses that must be paid for healthcare services by the covered person before the plan begins to share costs. CoInsurance is the percentage of medical expenses that you are responsible for aer your deducble has been sased. OutofPocket Maximum is the total amount of out of pocket expenses you will incur during the calendar year before your medical plans covers 100% of eligible charges. This amount excludes copays and deducbles.
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MedLink III - Supplemental Limited Benefit Medical Expense Insurance Summary of Benefits Benet Descripon
TRS AcveCare 2, Select & Sco & White
TRS AcveCare 1—HD
Coinsurance Percentage
100 %
100 %
Total Maximum Benet (Per Calendar Year)
$ 4,000 Per Person $ 12,000 Per Family
$ 4,000 Per Person $ 12,000 Per Family
InHospital Benet
$ 4,000 Per Person $ 12,000 Per Family
$ 4,000 Per Person $ 12,000 Per Family
OutPaent Hospital Benet Rider
Not Included
Not Included
Physician OutPaent Treatment Rider
Not Included
Not Included
$1,000 / $3,000
$2,400 / $4,800
$3,000 / $6,000 (Does Not Include Deducble or Copays)
$3,850 / $4,200 (Does Not Include Deducble or Copays)
$ 4,000 Per Person $ 9,000 Per Family
$ 6,250 Per Person $ 9,000 Per Family
Employee Only
$ 21.46
$ 26.74
Employee & Spouse
$ 49.34
$ 61.49
Employee & Child(ren)
$ 40.78
$ 50.81
Family
$ 68.66
$ 85.56
Employee Only
$ 38.58
$ 48.12
Employee & Spouse
$ 88.75
$ 110.69
Employee & Child(ren)
$ 73.32
$ 91.44
Family
$ 123.50
$ 153.98
TRS AcveCare Benets Deducble (per Plan Year; Individual / Family) OutofPocket Maximum (Per Plan Year; Individual / Family) Total Potenal OutofPocket Maximum (Per Plan Year; Individual / Family) Monthly Premium (Ages 18 54)
Monthly Premium (Ages 55 70)
Facts to Consider Wage and producvity losses and medical expenses averaged $18,058 per disabling injury in 20051 Out of Pocket hospital care ex penses are approximately $20.2 billion annually2 On average, one out of every eight emergency room department visits leads to a hospital admission3
Policy Benet Highlights InHospital Benet Pays 100% for incurred Covered Charges when a Covered Employee is conned to a Hospital as an Inpaent for at least 18 connuous hours and is covered under TRS Acve Care II and Sco & White Plans. Benets are payable up to the Maximum InHospital Benet. 1
Naonal Safety Council, Injury Facts 2007 Edion, p 4
2
Naonal Center for Health Stascs: Health, united States 2007
3
CDC: Advance Data from Vital & Health Stascs, Number 386, June 2007. Referencing the Naonal Hospital Ambulatory Medical Care Survey.
8
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10
Dental Insurance Plans Mid-Tex Educators Benets Cooperave
Why is dental health so important? Regular dental care does more than just improve smiles. Along with good oral hygiene, it can help you and your family lower your chances of serious health problems. Gum disease has been linked to a 50 percent rise in pancreatic and kidney cancer risk and a 30 percent increase in blood cell cancers.1
Research has shown, and experts agree, that there is an association between periodontal diseases and other chronic inflammatory conditions, such as diabetes, cardiovascular disease and Alzheimer’s disease.2
How can I get the coverage I need? Dental insurance offers you a convenient way to get regular dental care and can possibly help prevent life-threatening health problems. And through your employer, you can get this protection at an affordable group rate.
How do I know I’m eligible to participate in this plan? You can participate in this plan if you are a full-time employee of the policyholder or an associated company, and work in the United States. Full-time means working 20 hours or more per week. Temporary or seasonal workers are not eligible.
Key Advantages of This Plan Your plan includes our Lifetime of Smiles® program , with benefits many people prefer, such as up to four periodontal cleanings in a year3,4 and brush biopsies for the early detection of oral cancer.
Your plan includes Preventive Max Waiver®, which allows covered dental expenses for preventive service to not apply to the annual maximum.
Dental Health Alliance, L.L.C.® (DHA®), the network provider for your plan, includes more than 100,000+ unique dentists and offers you more options to save on fees and makes your annual maximum go even further.5
IMPORTANT: Coverage for eligible employees will begin September 1, 2013. You must sign up by the Initial Enrollment Deadline, or forfeit the opportunity until the next plan anniversary date. 1Journal
of Periodontology, January 2011.
2American
Academy of Periodontology - Website accessed June 3, 2011 http://www.perio.org/consumer/mbc.top2.htm.
3Classification 4Total
of services varies by plan design.
number of combined prophylaxis cleaning and periodontal maintenance procedures cannot exceed 4 in a 12 month period.
5 The
dental network provided by Assurant Employee Benefits includes 100,000+ unique dentists under access arrangements with Dental Health Alliance, L.L.C.® (DHA®) and other dental networks.
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Mid-Tex Educators Benets Cooperave
How does my plan work? Your plan covers a range of services for you and your family. Highlights of your benefits can be found below. Benefits are paid after any applicable deductible has been met, up to the annual maximum. For more specific information, please ask to see the certificate of insurance.
Why is Dental insurance a smart choice? Compare the annual cost of your Dental insurance with paying your dental expenses yourself:
How can using a network provider help lower my costs? You are free to use the dentist or specialist of your choice. However, when you choose a provider in Dental Health Alliance® (DHA®), your plan’s provider network, you can save money — up to 30%. Using a network provider may lower your out-of-pocket costs and can make your annual maximum go further. The dental network provided by Assurant Employee Benefits includes 100,000+ unique dentists under access arrangements with Dental Health Alliance® (DHA®) and other dental networks. To find a provider in your area, or to nominate your dentist to participate in DHA, go to www.assurantemployeebenefits.com, select For Members, then Find a dentist, or call Customer Service at 888.901.6377.
Who are eligible dependents? Those qualified to be covered under your dental plan include your spouse and children less than age 26. See your certificate or group insurance policy for additional eligibility details.
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Basic Dental Plan (100/80/50 ) Schedule of Benets In-Network Denst
Out-of-Network Denst
Calendar Year Maximum
$750
$750
Deducble
$50
$50
Waived for Preventave Services
Yes
Yes
Type 1 Preventave Services
100%
100%
Type 2 Basic Services
80%
80%
Type 3 Major Services
50%
50%
Negoated Fee
Negoated Fee
Orthodonc Services
Not Included
Not Included
Orthodonc Overall Maximum
Not Included
Not Included
Co-Insurance Amounts
Benet Payment
Your Plan Includes Lifeme of Smiles Preventave Max Waiver. Allows families and individuals to get roune dental care without tapping into
their annual maximum benet. Four cleaning per year to help prevent gum disease (coverage up to 4 periodontal cleanings in a 12
month period.)1,2,3 Posterior tooth-colored llings preferred by many densts and their paents. Brush Biopsies for early detecon of oral cancer. Periochips to control bacteria and reduce the size of periodontal pockets.
2,3 3
Genec Tesng to help idenfy individuals who are at genec risk for gum disease.
Dental Healthcare Discounts on Xylitol products clinically proven to help reduce cavies. Online Dental Health Center a trusted source that oers members the most up-to-date informaon
available on preventave dental care.
Monthly Premiums
Employee
$17.16
Employee + Spouse
$35.66
Employee + Child(ren)
$38.70
Employee + Family
$57.20
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Covered Dental Services (see certificate for a complete list of covered services) Schedule Covered Services Periodic Oral Evaluation
In-Network
Out-of-Network Coinsurance Percentages 100%
100%
Genetic Testing
100%
100%
Bitewing X-rays
100%
100%
Intraoral Complete Series/Panoromic XRays
100%
100%
Dental Prophylaxis
100%
100%
Topical Fluoride Treatment
100%
100%
Dental Sealants
100%
100%
Space Maintainers
80%
80%
Stainless Steel Crowns
50%
50%
Root Canals
50%
50%
Periodontal Scaling and Root Planing
50%
50%
Periodontal Maintenance
50%
50%
Periodontal Surgery
50%
50%
Simple Extractions
80%
80%
Biopsy
80%
80%
Complex Extractions
50%
50%
Incision & Drainage
80%
80%
General Anesthesia & IV Sedation
50%
50%
Palliative (emergency) Treatment of Pain
80%
80%
Fillings
80%
80%
Inlays, Onlays and Crowns
50%
50%
Dentures
50%
50%
Denture Repairs
80%
80%
Relining or Rebasing Dentures
50%
50%
Fixed Bridges
50%
50%
Not Included
Not Included
Implants Other Services Lifetime of Smiles®
Included
4
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Tradional Dental Plan (100/80/50 90th UCR) Schedule of Benets In-Network Denst
Out-of-Network Denst
$1,250
$1,250
Deducble
$50
$50
Waived for Preventave Services
Yes
Yes
Type 1 Preventave Services
100%
100%
Type 2 Basic Services
80%
80%
Type 3 Major Services
50%
50%
Negoated Fee
90th UCR
50%
50%
$1,500
$1,500
Calendar Year Maximum
Co-Insurance Amounts
Benet Payment
Orthodonc Services Orthodonc Overall Maximum
Your Plan Includes Lifeme of Smiles Preventave Max Waiver. Allows families and individuals to get roune dental care without tapping into
their annual maximum benet. Four cleaning per year to help prevent gum disease (coverage up to 4 periodontal cleanings in a 12
month period.)1,2,3 Posterior tooth-colored llings preferred by many densts and their paents. Brush Biopsies for early detecon of oral cancer. Periochips to control bacteria and reduce the size of periodontal pockets.
2,3 3
Genec Tesng to help idenfy individuals who are at genec risk for gum disease.
Dental Healthcare Discounts on Xylitol products clinically proven to help reduce cavies. Online Dental Health Center a trusted source that oers members the most up-to-date informaon
available on preventave dental care.
Monthly Premiums
Employee
$25.66
Employee + Spouse
$53.40
Employee + Child(ren)
$62.06
Employee + Family
$89.80
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Covered Dental Services (see certificate for a complete list of covered services) Schedule Covered Services Periodic Oral Evaluation
In-Network
Out-of-Network Coinsurance Percentages 100%
100%
Genetic Testing
100%
100%
Bitewing X-rays
100%
100%
Intraoral Complete Series/Panoromic XRays
100%
100%
Dental Prophylaxis
100%
100%
Topical Fluoride Treatment
100%
100%
Dental Sealants
100%
100%
Space Maintainers
80%
80%
Stainless Steel Crowns
50%
50%
Root Canals
50%
50%
Periodontal Scaling and Root Planing
80%
80%
Periodontal Maintenance
80%
80%
Periodontal Surgery
50%
50%
Simple Extractions
80%
80%
Biopsy
80%
80%
Complex Extractions
80%
80%
Incision & Drainage
80%
80%
General Anesthesia & IV Sedation
80%
80%
Palliative (emergency) Treatment of Pain
80%
80%
Fillings
80%
80%
Inlays, Onlays and Crowns
50%
50%
Dentures
50%
50%
Denture Repairs
80%
80%
Relining or Rebasing Dentures
50%
50%
Fixed Bridges
50%
50%
Implants Class IV Orthodonic Services Orthodonic Benefit Other Services Lifetime of Smiles®
Not Included
Not Included Adult and Child
50%
50% Included
Preventative Max Waiver®
Included
4
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Network Max Ulizaon Dental Plan (100/100/60 MAC) Schedule of Benets In-Network Denst
Out-of-Network Denst
$1,250
$1,250
Deducble
$50
$50
Waived for Preventave Services
Yes
Yes
Type 1 Preventave Services
100%
100%
Type 2 Basic Services
100%
100%
Type 3 Major Services
60%
60%
Negoated Fee
Negoated Fee
50%
50%
$1,500
$1,500
Calendar Year Maximum
Co-Insurance Amounts
Benet Payment
Orthodonc Services Orthodonc Overall Maximum
Your Plan Includes Lifeme of Smiles Preventave Max Waiver. Allows families and individuals to get roune dental care without tapping into
their annual maximum benet. Four cleaning per year to help prevent gum disease (coverage up to 4 periodontal cleanings in a 12
month period.)1,2,3 Posterior tooth-colored llings preferred by many densts and their paents. Brush Biopsies for early detecon of oral cancer. Periochips to control bacteria and reduce the size of periodontal pockets.
2,3 3
Genec Tesng to help idenfy individuals who are at genec risk for gum disease.
Dental Healthcare Discounts on Xylitol products clinically proven to help reduce cavies. Online Dental Health Center a trusted source that oers members the most up-to-date informaon
available on preventave dental care.
Monthly Premiums
Employee
$25.66
Employee + Spouse
$53.40
Employee + Child(ren)
$62.06
Employee + Family
$89.80
17
Covered Dental Services (see certificate for a complete list of covered services) Schedule Covered Services Periodic Oral Evaluation
In-Network
Out-of-Network Coinsurance Percentages 100%
100%
Genetic Testing
100%
100%
Bitewing X-rays
100%
100%
Intraoral Complete Series/Panoromic XRays
100%
100%
Dental Prophylaxis
100%
100%
Topical Fluoride Treatment
100%
100%
Dental Sealants
100%
100%
Space Maintainers
100%
100%
Stainless Steel Crowns
60%
60%
Root Canals
60%
60%
Periodontal Scaling and Root Planing
100%
100%
Periodontal Maintenance
100%
100%
Periodontal Surgery
60%
60%
Simple Extractions
100%
100%
Biopsy
100%
100%
Complex Extractions
100%
100%
Incision & Drainage
100%
100%
General Anesthesia & IV Sedation
100%
100%
Palliative (emergency) Treatment of Pain
100%
100%
Fillings
100%
100%
Inlays, Onlays and Crowns
60%
60%
Dentures
60%
60%
Denture Repairs
100%
100%
Relining or Rebasing Dentures
60%
60%
Fixed Bridges
60%
60%
Implants Class IV Orthodonic Services Orthodonic Benefit Other Services Lifetime of Smiles®
Not Included
Not Included Adult and Child
50%
50% Included
Preventative Max Waiver®
Included
4
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General Informaon
Waiting Periods No waiting periods for exams, cleanings, and fillings. A Timely Applicant Waiting Period of 12 months for Class III Major Services applies to all employees who enroll in this dental plan within 31 days of becoming eligible.
A Timely Applicant Waiting Period of 12 months for Orthodontic Services applies to all employees and dependents who enroll in this dental plan within 31 days of becoming eligible.
Transfer Treatment Transfer treatment occurs when the policyholder has had dental coverage immediately preceding this coverage effective date. No waiting periods will apply if the employee or the employee’s dependents were covered under the policyholder’s prior plan on the day before it was replaced by this plan. Transfer treatment only applies to services that are covered under both plans.
Transfer treatment means that we will pay pro-rated benefits for treatment in progress, as long as the expense is a covered expense under both plans. For this to occur, such employees must enroll in this dental plan within 31 days of becoming eligible.
Exclusions Treatment or an appliance which is not dentally necessary, is experimental or temporary in nature, or does not have uniform professional endorsement, treatment related to procedures that are part of a service but are not reported as separate services, reported in a treatment sequence that is not appropriate or misreported or that represent a procedure other than the one reported, appliances, inlays, cast restorations, crowns, or other laboratory prepared restorations used primarily for the purpose of splinting, any treatment or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension, the alteration or restoration of occlusion, except for occlusal adjustment in conjunction with periodontal surgery or temporomandibular joint disorder, bite registration, bite analysis, attrition or abrasion, replacement of a lost or stolen appliance or prosthesis, educational procedures, including but not limited to oral hygiene, plaque control or dietary instructions, completion of claim forms or missed dental appointments, personal supplies or equipment, including but not limited to water piks, toothbrushes, floss holders, or athletic mouthguards, administration of nitrous oxide or any other agent to control anxiety, treatment for a jaw fracture, treatment provided by a dentist, dental hygienist, or denturist who is an immediate family member or a person who ordinarily resides with a covered person, an employee of the policyholder, or a policyholder, hospital or facility charges for room, supplies or emergency room expenses or routine chest x-rays and medical exams prior to oral surgery, treatment provided primarily for cosmetic purposes, treatment which may not reasonably be expected to successfully correct the person's dental condition for a period of at least 3 years, crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth which do not have extensive decay or fracture and can be restored with an amalgam or composite resin filling, treatment for implants, implant abutments, implant supported prosthetics (crown, fixed partial denture, dentures) or any other services related to the care and treatment of the implant, treatment for the prevention of bruxism (grinding of teeth). Treatment performed outside the United States, except for emergency dental treatment (the maximum benefit payable to any person during a benefit year for covered dental expenses related to emergency dental treatment performed outside the United States is $100), treatment or appliances at which are covered under any Workers’ Compensation Law, Employer's Liability Law or similar law (a person must promptly claim and notify us of all such benefits), treatment for which a charge would not have been made in the absence of insurance, treatment for which a covered person does not have to pay, except when payment of such benefits is required by law and only to the extent required by law.
19
Online Advantage for Members Assurant Employee Benefits offers you online service capability to help manage your dental care! With a click of a mouse you have immediate access to your plan information with Online Advantage for Members. Features at your fingertips: • View eligibility • View benefit details* • View claims status • Find a dentist and/or specialist • Request ID card
• Change facility for prepaid members • Dental fee cost estimator • Ask a dentist • Dental health center • Contact customer service
Registering for Online Advantage To register go to www.assurantemployeebenefits.com, in the Online Advantage Login go to Register Now. All you will need is your Member ID# and date of birth, it’s that easy! You can login anytime to view your plan information. For more information about how Online Advantage can work for you please visit the online demo, call customer service at 800.442.7742 or email
[email protected].
Online Advantage is quick, smart, and convenient! www.assurantemployeebenefits.com Products and services marketed by Assurant Employee Benefits are underwritten by Union Security Insurance Company or an affiliated prepaid dental company. In New York, products and services marketed by Assurant Employee Benefits are underwritten by Union Security Life Insurance Company of New York, which is licensed in New York and has its principal place of business in Syracuse, New York. This policy provides DENTAL insurance only.
20
Policy Nos. GP90 PF99 and BDC-GDSA-NY ©2008 Assurant KC4545A-J (4/2008)
Gold $150 VISION PLAN $10 Exam/$25 Eyewear Copayments Full Service – Illustration Service / Material Participating Provider Non-Participating Provider 1 Vision Examination: Paid in full Up to: $35.00 Retail Value1 Frame:
Up to: $150.00 Retail Value1
Up to: $70.00 Retail Value1
Lenses: (Clear, Standard, Glass or Plastic) Single Vision (per pair) Paid in full1 Up to: $25.00 Retail Value1 Bifocal (per pair) Paid in full1 Up to: $40.00 Retail Value1 2 1 Trifocal (per pair) Paid in full Up to: $45.00 Retail Value1 Lenticular (per pair) Paid in full1 Up to: $80.00 Retail Value1 3 Contact Lenses: Elective Up to $175.001 Up to: $80.00 Retail Value1 1 Medically Required Paid in full Up to: $150.00 Retail Value1 Laser Vision Correction: $200.00 allowance (in or out of network) - (Laser Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations) 1 2 3
After applicable copayment listed above is fulfilled. Member pays difference in retail price between standard trifocal lenses and progressive lenses. Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglasses. Coverage to include all contact lens types (i.e. standard daily wear, extended wear, disposable, toric, gas permeable, and bifocal).
Frequency: Vision Examination Frame Lenses Contact Lenses (in lieu of eyeglasses) Rates: Voluntary Participation Employee Employee + 1 Family
Once Each 12 Months Once Each 24 Months Once Each 12 Months Once Each 12 Months Monthly $ 6.97 $11.85 $17.43
Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Wal-Mart Vision Center does not qualify for this additional discount because of Wal-Mart’s “Always Low Prices” policy.
WE FOCUS ON YOU SO YOU CAN FOCUS ON LIFE
FOR MORE INFORMATION PLEASE CONTACT US TOLL-FREE AT (866) 265-0517 OR VISIT OUR WEBSITE AT www.blockvision.com
2/5/2013
21
22
What is the difference between an Optometrist and Ophthalmologist? Both are known as eye doctors and both perform eye examinations. An Optometrist is an eye specialist. An Ophthalmologist is an "eye surgeon." Some of our network Optometrists are now licensed to treat eye infections, prescribe medication and remove foreign bodies.
Am I able to obtain eyeglasses and contact lenses in the same year? No. Block Vision’s plan provides coverage for eyeglasses or contact lenses, but not both, within the stated benefit period.
Contact lenses and related professional services with a retail value of up to $175 are covered in lieu of eyeglasses. Coverage includes the complete contact lens package (contact lenses and related professional services specific to contact lens fitting, evaluation and follow-up). Members receive a $175 retail allowance toward the purchase of contact lenses that retail for more than $175.
If you choose a non-participating provider, you will be expected to pay the doctor for services received. You will then need to send the original receipt from your nonparticipating doctor to Block Vision for reimbursement. Block Vision will review your eligibility and send the appropriate reimbursement to you.
How do I use this plan? With your vision benefit, choose a provider from the participating provider list. Present your ID card for services at the time of service. EXCEPT FOR ANY APPLICABLE COPAYMENT, DO NOT PAY YOUR PARTICIPATING PROVIDER FOR SERVICES OR EYEWEAR COVERED BY YOUR BLOCK VISION BENEFIT.
How do I enroll in this plan? You must complete the enrollment form furnished to you. At enrollment, you should mark your coverage selection (i.e. employee, employee+ 1, or family). If you select employee+ 1, or family, be sure to include all the information requested for covered dependents, including social security numbers and birth dates.
What plan options are available? Mid-Tex EBC employees are being offered our Gold $150 plan. The Gold $150 plan includes a routine/basic vision examination yearly. The eyewear benefit provides coverage for lenses or contacts every year and provides up to $150 coverage for frames every other year.
What if I have other questions? You may call Block Vision’s office toll-free at (866) 265-0517, Monday through Friday 8:00 AM to 5:00 PM (CST) with any questions you may have. If you call during evening or weekend hours, you will be able to leave a message on the Block Vision voice mail system. Your call will be returned as soon as possible.
What type of eyeglass lenses am I eligible for? What about Progressive Lenses? Tints? All Block Vision’s plans cover clear, standard glass or plastic lenses, with single vision, bifocal or trifocal. You may choose to upgrade your lenses by paying the difference over and above the standard lens price. For example, if you want an antireflective coating on your lenses, the plan will pay for the standard lens and you are responsible for the cost of the anti-reflective coating. If you would like progressive lenses, your benefit will pay for standard trifocal lenses and you will pay any amount over and above the standard trifocal price. Tinting, coating and any other "additions" to your lenses are added at your own expense. Block Vision will pay for the clear, standard glass or plastic lenses with single vision, bifocal or trifocal prescriptions.
If I wear disposable contact lenses, must I use my entire benefit at one time? No. You may continue to make use of the remaining amount of your contact lens benefit during the benefit frequency stated in your plan. For example, if you need disposable lenses once every three months, then that is the way you obtain your lenses in the Block Vision plan until such time as your benefit maximum has been reached. Any remaining benefit values at the end of the benefit period are not carried over to the next benefit period.
How will the Block Vision provider determine what I am eligible to receive? Employees electing single coverage will receive 1 ID card. Employees electing employee+ 1, or family coverage will be issued 2 ID cards. The Block Vision ID card enables the Block Vision provider to access Block Vision’s computer system to determine what you are eligible to receive. Please be aware that your eligibility with Block Vision is calculated on a date of service - to date of service method, not calendar year. For example, if you are entitled to an exam once each 12 months and receive your first exam on 8-11-13, you will become eligible again for a new exam on 8-11-14.
Vision Plan Questions & Answers
How to print your temporary ID card Have you lost your Member ID card? Or, maybe you have not received your Member ID card yet?
Step 1: Go to www.BlockVision.com
Step 2: Along the top of the webpage, there are five categories. Hold your mouse over Block Vision and You, then hold your mouse over Members/Prospective Did you know?? Members and then click on Group Members. You can call Block Vision’s Member Step 3: On the right hand side of the page, under the Yellow bolded heading, “Member Login”, click the fourth bullet point “Print Temporary ID Card”.
Services Center with questions you may have about plan usage, finding a provider or other general benefit questions at:
(866) 265-0517
Step 4: When prompted to Login, choose “Member” in the drop box of options. Step 5: Enter your Member ID (If you know the number). If not, enter your Social Security Number and Date of Birth. Step 6: Towards the bottom of the webpage, under Dependent Information, click the option called “Print ID Card”.
Block Vision...The Clear Choice
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www.blockvision.com
Educator Select Income Protection Plan Insurance Highlights
Mid-Tex Educators Benefits Cooperative
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Worksite Modification
Waiver of Premium
Survivor Benefit
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Dependent Care Expense Benefit
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Worldwide Emergency Travel 2 Assistance Services
Other Important Provisions Pre-existing Condition
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27
Exclusion
Continuity of Coverage
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Medical Treatment Benefit
$0HGLFDO7UHDWPHQW%HQHILWZLOOEHSDLGZKHQ\RXUHFHLYHWUHDWPHQWE\D GRFWRUDVDUHVXOWRIDVLFNQHVVRULQMXU\SURYLGHGQRRWKHUEHQHILWVDUH SD\DEOHXQGHUWKHSODQDVDUHVXOWRIWKHFRQGLWLRQIRUZKLFKWKHWUHDWPHQW ZDVUHQGHUHG 7KH0HGLFDO7UHDWPHQW%HQHILWZLOOEHWKHGRFWRU VDFWXDOFKDUJHIRU VHUYLFHVUHQGHUHGXSWRDPD[LPXPEHQHILWRIIRUVLFNQHVVRUIRU LQMXU\,QDGGLWLRQWKHFKDUJHVPXVWEHIRUPHGLFDOO\QHFHVVDU\FDUHDQG
28
WUHDWPHQWDQGLQNHHSLQJZLWKWKHH[WHQWRIWKHVLFNQHVVRULQMXU\ 1REHQHILWZLOOEHSDLGXQOHVV\RXDUHSHUVRQDOO\VHHQDQGWUHDWHGE\D GRFWRUDQGWKHWUHDWPHQWLVQRWIRUURXWLQHPHGLFDOH[DPLQDWLRQVRUGHQWDO ZRUN Note: No more than one Medical Treatment Benefit will be paid for the same or related condition(s) unless the treatment dates are separated by at least 14 consecutive days. In addition, no more than one benefit will be paid for treatment during any 24 hour period and the benefit will not be paid more than 4 times per calendar year.
Gainful Occupation
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Benefit Integration
Your disability benefit will be reduced by deductible sources of income and any earnings you have while disabled.
Mental Illness/Self-Reported Symptoms
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Instances When Benefits Would Not Be Paid
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Termination of Coverage
Next Steps
How to Apply/ Effective Date of Coverage
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Questions
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32
Term Life Insurance and AD&D Coverage Highlights
Mid-Tex Educators Benefits Cooperative Please read carefully the following description of your Unum Term Life and AD&D insurance plan.
Your Plan Eligibility
All employees working at least 20 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 26.
Coverage Amounts
Your Term Life coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. Spouse:
Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee.
Child:
Up to 100% of employee coverage amount in increments of $2,000. Not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1000. Benefits will be paid to the employee. In order to purchase Life coverage for your spouse and/or child, you must purchase Life coverage for yourself.
Your AD&D coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. You may purchase AD&D coverage for yourself regardless of whether you purchase Life coverage. Spouse:
Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee.
Child:
Up to 100% of employee coverage amount in increments of $2,000. Not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself.
AD&D Benefit Schedule: The full benefit amount is paid for loss of: x Life x Both hands or both feet or sight of both eyes x One hand and one foot x One hand and the sight of one eye x One foot and the sight of one eye x Speech and hearing Other losses may be covered as well. Please see your Plan Administrator. ADR1879-2001
33
Term Life Insurance and AD&D Coverage Highlights (Continued) Coverage amount(s) will reduce according to the following schedule: Age: 70 75
Insurance Amount Reduces to: 65% of original amount 50% of original amount
Coverage may not be increased after a reduction. Current Employees: If you and your eligible dependents enroll on or before the enrollment deadline, you may apply for any amount of Life insurance coverage up to $150,000 for yourself and any amount of coverage up to $25,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll on or before the enrollment deadline, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of Life insurance coverage. AD&D coverage does not require evidence of insurability.
Guarantee Issue
If you and your eligible dependents enroll on or before the enrollment deadline, and later wish to increase your Life insurance coverage, you may increase your coverage with evidence of insurability at anytime during the year. However, you may wait until the next annual enrollment and only coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. Newly Hired Employees: If you and your eligible dependents enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance coverage up to $150,000 for yourself and any amount of coverage up to $25,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your Life insurance coverage, with evidence of insurability, at anytime during the year. However, you may wait until the next annual enrollment and only Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. Please see your Plan Administrator for your eligibility date.
Additional Benefits Life Planning Financial & Legal Resources
This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. The financial consultants are master level consultants. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security. At no time will the consultants offer or sell any product or service.
34
Term Life Insurance and AD&D Coverage Highlights (Continued) Portability/Conversion
If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy.
Accelerated Benefit
If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 100% of your life insurance amount up to $250,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies). This feature also applies to your covered dependents.
Waiver of Premium
If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability.
Retained Asset Account
Benefits of $10,000 or more are paid through the Unum Retained Asset Account. This interest bearing account will be established in the beneficiary's name. He or she can then write a check for the full amount or for $250 or more, as needed.
Additional AD&D Benefits
Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.) Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.
Limitations/Exclusions/ Termination of Coverage Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage.
Suicide Exclusion
No increased or additional benefits will be payable for deaths caused by suicide occurring within 24 months after the day such increased or additional insurance is effective. AD&D Benefit Exclusions
AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from: x
Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders;
x
Suicide, self-destruction while sane, intentionally self-inflicted injury while sane, or self-inflicted injury while insane;
x
War, declared or undeclared, or any act of war;
35
Term Life Insurance and AD&D Coverage Highlights (Continued)
Termination of Coverage
x
Active participation in a riot;
x
Attempt to commit or commission of a crime;
x
The voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol;
x
Intoxication. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.)
Your coverage and your dependents’ coverage under the Summary of Benefits ends on the earliest of: x
The date the policy or plan is cancelled;
x
The date you no longer are in an eligible group;
x
The date your eligible group is no longer covered;
x
The last day of the period for which you made any required contributions;
x
The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage;
x
For dependent’s coverage, the date of your death.
In addition, coverage for any one dependent will end on the earliest of: x
The date your coverage under a plan ends;
x
The date your dependent ceases to be an eligible dependent;
x
For a spouse, the date of divorce or annulment.
Unum will provide coverage for a payable claim which occurs while you and your dependents are covered under the policy or plan.
Next Steps Current Employees: To apply for coverage, complete your online enrollment by the enrollment deadline.
How to Apply
Newly Hired Employees: To apply for coverage, complete your online enrollment form within 31 days of your eligibility date. All Employees: If you apply for coverage after your effective date, or if you choose coverage over the guarantee issue amount, you will need to complete a medical questionnaire which you can get from your Plan Administrator. You may also be required to take certain medical tests at Unum’s expense.
36
Term Life Insurance and AD&D Coverage Highlights (Continued) Effective Date of Coverage
Please see your Plan Administrator for your coverage effective date.
Delayed Effective Date of Coverage
Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth. “Totally disabled” means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life threatening condition.
Changes to Coverage
Each year you and your spouse will be given the opportunity to change your Life coverage and AD&D coverage. You and your spouse may purchase additional Life coverage up to the Guarantee Issue amounts without evidence of insurability if you are already enrolled in the plan. Life coverage over the Guarantee Issue amounts will be medically underwritten and will require evidence of insurability and approval by Unum’s Medical Underwriters. The suicide exclusion will apply to any increase in coverage. AD&D coverage does not require evidence of insurability for increase amounts. If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.
Questions
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. Life Planning is provided by Ceridian Incorporated. The services are subject to availability and may be withdrawn by Unum without prior notice.
Underwritten by: Unum Life Insurance Company of America, 2211 Congress Street, Portland, Maine 04122, www.unum.com Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. ©2007 Unum Group. All rights reserved.
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$
0.60
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0.66
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0.80
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1.07
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1.44
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2.13
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3.17
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11.27
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19.84
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40.16
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0.30
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0.33
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5.64
$
9.92
$
20.08
$5,000
$
0.60
$
0.66
$
0.80
$
1.07
$
1.44
$
2.13
$
3.17
$
4.64
$
6.80
$
11.27
$
19.84
$
40.16
$10,000
$
1.20
$
1.32
$
1.60
$
2.14
$
2.88
$
4.26
$
6.34
$
9.28
$
13.60
$
22.54
$
39.68
$
80.32
$20,000
$
0.90
$
0.99
$
1.20
$
1.61
$
2.16
$
3.20
$
4.76
$
6.96
$
10.20
$
16.91
$
29.76
$
60.24
$15,000
$
1.80
$
1.98
$
2.40
$
3.21
$
4.32
$
6.39
$
9.51
$
13.92
$
20.40
$
33.81
$
59.52
$
120.48
$30,000
$
1.20
$
1.32
$
1.60
$
2.14
$
2.88
$
4.26
$
6.34
$
9.28
$
13.60
$
22.54
$
39.68
$
80.32
$20,000
$
2.40
$
2.64
$
3.20
$
4.28
$
5.76
$
8.52
$
12.68
$
18.56
$
27.20
$
45.08
$
79.36
$
160.64
$40,000
$
1.50
$
1.65
$
2.00
$
2.68
$
3.60
$
5.33
$
7.93
$
11.60
$
17.00
$
28.18
$
49.60
$
100.40
$25,000
$
3.00
$
3.30
$
4.00
$
5.35
$
7.20
$
10.65
$
15.85
$
23.20
$
34.00
$
56.35
$
99.20
$
200.80
$50,000
$
1.80
$
1.98
$
2.40
$
3.21
$
4.32
$
6.39
$
9.51
$
13.92
$
20.40
$
33.81
$
59.52
$
120.48
$30,000
$
3.60
$
3.96
$
4.80
$
6.42
$
8.64
$
12.78
$
19.02
$
27.84
$
40.80
$
67.62
$
119.04
$
240.96
$60,000
$
2.10
$
2.31
$
2.80
$
3.75
$
5.04
$
7.46
$
11.10
$
16.24
$
23.80
$
39.45
$
69.44
$
140.56
$35,000
$
4.20
$
4.62
$
5.60
$
7.49
$
10.08
$
14.91
$
22.19
$
32.48
$
47.60
$
78.89
$
138.88
$
281.12
$70,000
$
2.40
$
2.64
$
3.20
$
4.28
$
5.76
$
8.52
$
12.68
$
18.56
$
27.20
$
45.08
$
79.36
$
160.64
$40,000
$
4.80
$
5.28
$
6.40
$
8.56
$
11.52
$
17.04
$
25.36
$
37.12
$
54.40
$
90.16
$
158.72
$
321.28
$80,000
$
3.00
$
3.30
$
4.00
$
5.35
$
7.20
$
10.65
$
15.85
$
23.20
$
34.00
$
56.35
$
99.20
$
200.80
$50,000
$
5.40
$
5.94
$
7.20
$
9.63
$
12.96
$
19.17
$
28.53
$
41.76
$
61.20
$
101.43
$
178.56
$
361.44
$90,000
$
6.00
$
6.60
$
8.00
$
10.70
$
14.40
$
21.30
$
31.70
$
46.40
$
68.00
$
112.70
$
198.40
$
401.60
$100,000
$
6.00
$
6.60
$
8.00
$
10.70
$
14.40
$
21.30
$
31.70
$
46.40
$
68.00
$
112.70
$
198.40
$
401.60
$100,000
$
9.00
$
9.90
$
12.00
$
16.05
$
21.60
$
31.95
$
47.55
$
69.60
$
102.00
$
169.05
$
297.60
$
602.40
$150,000
$
7.20
$
7.92
$
9.60
$
12.84
$
17.28
$
25.56
$
38.04
$
55.68
$
81.60
$
135.24
$
238.08
$
481.92
$120,000
$
7.80
$
8.58
$
10.40
$
13.91
$
18.72
$
27.69
$
41.21
$
60.32
$
88.40
$
146.51
$
257.92
$
522.08
$130,000
$
9.00
$
9.90
$
12.00
$
16.05
$
21.60
$
31.95
$
47.55
$
69.60
$
102.00
$
169.05
$
297.60
$
602.40
$150,000
$10,000
$
0.90 $
1.80
$5,000
CHILDRATES
$
8.40
$
9.24
$
11.20
$
14.98
$
20.16
$
29.82
$
44.38
$
64.96
$
95.20
$
157.78
$
277.76
$
562.24
$140,000
YOUR SPOUSE MAY CHOOSE ANY INCREMENT OF $5,000 UP TO $500,000 ( NOT TO EXCEED 100% OF THE EMPLOYEE AMOUNT.
SPOUSE'S RATES ARE CALCULATED USING THE SPOUSES AGE.
THESE RATE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS OF COVERAGE.
YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000 ( NOT TO EXCEED 5 TIMES YOUR ANNUAL SALARY).
YOUR AGE IS
CALCULATED AS OF YOUR AGE AS OF THE ANNIVERSARY OF THE POLICY.
SPOUSERATESCANNOTEXCEED100%OFEMPLOYEESAMOUNT
AgeBand 024 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75+
SPOUSERATES
AgeBand 024 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75+
EMPLOYEERATES
MonthlyPayrollDeduction
UNUMCORPORATIONLIFESTYLELIFERATES MidTexEducatorsBenefitsCooperative
,IFE )NSURANCE (IGHLIGHTS
PURELIFE PLUS
&OR THE EMPLOYEE &LEXIBLE 0REMIUM ,IFE )NSURANCE TO !GE 0OLICY &ORM 02&.' .) 6OLUNTARY PERMANENT LIFE INSURANCE CAN BE AN IDEAL COMPLEMENT TO THE GROUP TERM AND OPTIONAL TERM YOUR EMPLOYER MIGHT PROVIDE $ESIGNED TO BE IN FORCE WHEN YOU DIE THIS VOLUNTARY UNIVERSAL LIFE PRODUCT IS YOURS TO KEEP EVEN WHEN YOU CHANGE JOBS OR RETIRE AS LONG AS YOU PAY THE NECESSARY PREMIUM 'ROUP AND VOLUNTARY TERM ON THE OTHER HAND TYPICALLY ARE NOT PORTABLE IF YOU CHANGE JOBS AND EVEN IF YOU CAN KEEP THEM AFTER YOU RETIRE USUALLY COSTS MORE AND DECLINES IN DEATH BENE½T 4HE POLICY PURELIFE PLUS IS UNDERWRITTEN BY 4EXAS ,IFE )NSURANCE #OMPANY AND IT HAS THESE OUTSTANDING FEATURES
(IGH $EATH "ENE½T 7ITH ONE OF THE HIGHEST DEATH BENE½TS AVAILABLE AT THE WORKSITE PURELIFE PLUS GIVES YOUR LOVED ONES PEACE OF MIND KNOWING THERE WILL BE SIGNI½CANT LIFE INSURANCE IN FORCE SHOULD YOU DIE PREMATURELY
-INIMAL #ASH 6ALUE $ESIGNED TO PROVIDE HIGH DEATH BENE½T PURELIFE PLUS DOES NOT COMPETE WITH THE CASH ACCUMULATION IN YOUR EMPLOYER SPONSORED RETIREMENT PLANS
,ONG 'UARANTEES %NJOY THE ASSURANCE OF A POLICY THAT HAS A GUARANTEED DEATH BENE½T TO AGE AND LEVEL PREMIUM THAT GUARANTEES COVERAGE FOR A SIGNI½CANT PERIOD OF TIME AFTER THE GUARANTEED PERIOD PREMIUMS MAY GO DOWN STAY THE SAME OR GO UP
2EFUND OF 0REMIUM 5NIQUE IN THE MARKETPLACE PURELIFE PLUS OFFERS YOU A REFUND OF YEARS´ PREMIUM SHOULD YOU SURRENDER THE POLICY IF THE PREMIUM YOU PAY WHEN YOU BUY THE POLICY EVER INCREASES #ONDITIONS APPLY
!CCELERATED $EATH "ENE½T 2IDER 3HOULD YOU BE DIAGNOSED AS TERMINALLY ILL WITH THE EXPECTATION OF DEATH WITHIN MONTHS MONTHS IN )LLINOIS YOU WILL HAVE THE OPTION TO RECEIVE IN )LLINOIS OF THE DEATH BENE½T MINUS A IN &LORIDA ADMINISTRATIVE FEE 4HIS VALUABLE LIVING BENE½T GIVES YOU PEACE OF MIND KNOWING THAT SHOULD YOU NEED IT YOU CAN TAKE THE LARGE MAJORITY OF YOUR DEATH BENE½T WHILE STILL ALIVE #ONDITIONS APPLY 9OU MAY APPLY FOR THIS PERMANENT PORTABLE COVERAGE NOT ONLY FOR YOURSELF BUT ALSO FOR YOUR SPOUSE MINOR CHILDREN AND GRANDCHILDREN
,IKE MOST LIFE INSURANCE POLICIES 4EXAS ,IFE POLICIES CONTAIN CERTAIN EXCLUSIONS LIMITATIONS EXCEPTIONS REDUCTIONS OF BENE½TS WAITING PERIODS AND TERMS FOR KEEPING THEM IN FORCE 0LEASE CONTACT A 4EXAS ,IFE REPRESENTATIVE FOR COSTS AND COMPLETE DETAILS
6OLUNTARY AND 5NIVERSAL 7HOLE ,IFE 0RODUCTS %ASTBRIDGE #ONSULTING 'ROUP /CTOBER
3EE THE PURELIFE PLUS BROCHURE FOR DETAILS
- # %XPIRES
39
.OT FOR USE IN 7!
)NFORMATION ABOUT 052%,)&% PLUS -INIMAL #ASH 6ALUES "UY THIS POLICY FOR ITS LIFE INSURANCE PROTECTION NOT ITS CASH VALUE 4HE PRIMARY BENE½T IS LIFE INSURANCE 0AYMENT OF THE 4ABLE 0REMIUM PRODUCES A SMALL CASH VALUE "ENCHMARK #ASH 6ALUE 0ERMANENT ,IFE )NSURANCE #OVERAGE 5NLIKE GROUP TERM LIFE INSURANCE 0URE,IFE PLUS IS A PERSONALLY OWNED PERMANENT INDIVIDUAL LIFE INSURANCE POLICY TO AGE THAT CAN NEVER BE CANCELED OR REDUCED AS LONG AS YOU PAY THE NECESSARY PREMIUMS EVEN IF YOUR HEALTH CHANGES 'UARANTEED 0ERIOD #ONTINUOUS TIMELY AND UNINTERRUPTED PAYMENT OF THE 4ABLE 0REMIUM GUARANTEES COVERAGE FOR THE 'UARANTEED 0ERIOD STATED IN THE POLICY 4EXAS ,IFE 7E CANNOT LEGALLY PREDICT THE PREMIUM REQUIRED TO CONTINUE COVERAGE AFTER THE 'UARANTEED 0ERIOD )T MAY BE LOWER THE SAME OR HIGHER THAN THE 4ABLE 0REMIUM (OWEVER IF THE PREMIUM TO CONTINUE COVERAGE IS EVER HIGHER 7E GUARANTEE A LIMITED RIGHT TO A PARTIAL REFUND OF PREMIUM 'UARANTEED ,IMITED 2IGHT TO 0ARTIAL 2EFUND OF 0REMIUM )F A PREMIUM HIGHER THAN THE 4ABLE 0REMIUM IS EVER REQUIRED TO CONTINUE COVERAGE AFTER THE 'UARANTEED 0ERIOD YOU HAVE THE CHOICE TO A PAY THE HIGHER PREMIUMS REQUIRED TO CONTINUE COVERAGE OR B SURRENDER THE POLICY AND RECEIVE A PARTIAL REFUND OF PREMIUM EQUAL TO TIMES THE MINIMUM MONTHLY PREMIUM DUE AT ISSUE YEARS WORTH OF 4ABLE 0REMIUM 9OU ARE ELIGIBLE FOR THIS REFUND IF THE ACTUAL CASH VALUE EQUALS OR EXCEEDS THE "ENCHMARK #ASH 6ALUE AND YOU HAVE TAKEN NO PRIOR PARTIAL SURRENDERS #ONDITIONS APPLY !CCELERATED $EATH "ENEFIT &OR NO ADDED PREMIUM THE POLICY INCLUDES AN !CCELERATED $EATH "ENE½T $UE TO 4ERMINAL )LLNESS 2IDER &ORM 5,!"2 ±4ERMINAL #ONDITION² IN 0! )F THE INSURED BECOMES TERMINALLY ILL OR HAS A TERMINAL CONDITION IN 0! OR A QUALIFYING EVENT IN A STATE WITH )## IN THE POLICY FORM NUMBER YOU MAY ELECT TO CLAIM AN ACCELERATED BENE½T WHILE THE INSURED IS STILL ALIVE IN LIEU OF THE INSURANCE PROCEEDS PAYABLE AT DEATH )N MOST STATES THE SINGLE SUM BENE½T IS IN ), OF THE INSURANCE PROCEEDS 4HERE IS ALSO AN ADMINISTRATIVE FEE OF IN &, 4HIS IS NOT A LONG TERM CARE BENE½T 4ERMINAL )LLNESS OR #ONDITION IS AN INJURY OR SICKNESS DIAGNOSED AND CERTI½ED BY A QUALIFYING PHYSICIAN THAT DESPITE APPROPRIATE MEDICAL CARE IS REASONABLY EXPECTED TO RESULT IN DEATH WITHIN MONTHS MONTHS IN ), 7E CAN AT OUR EXPENSE REQUEST THE OPINION OF A PHYSICIAN 7E CHOOSE ! DAY EXCLUSION PERIOD APPLIES UNLESS THE TERMINAL ILLNESS RESULTS FROM ACCIDENTAL BODILY INJURY DAYS IN #4 ), ,! -$ 54 DAYS IN /2 0! 3# /THER CONDITIONS AND LIMITATIONS APPLY 0AY PREMIUMS FAITHFULLY 4HE RIDER TERMINATES IF THE POLICY EVER LAPSES FOR NON PAYMENT OF PREMIUM EVEN IF THE POLICY IS LATER REINSTATED 4HE RIGHT TO ACCELERATE BENE½TS UNDER THIS RIDER DOES NOT EXTEND TO ANY #HILD 4ERM ,IFE )NSURANCE 2IDER (OWEVER IF THE ACCELERATED BENE½T IS PAID THE #HILD 2IDER BECOMES PAID UP TERM INSURANCE TO EACH INSURED CHILD´S AGE 0AYMENT OF THE !CCELERATED $EATH "ENE½T TERMINATES THE POLICY AND ALL OPTIONAL BENE½TSRIDERS WITHOUT FURTHER VALUE - # EXP .OT FOR USE IN 7!
40
#HILD 4ERM ,IFE )NSURANCE 2IDER )N LIEU OF AN INDIVIDUAL POLICY ON EACH CHILD IF THE PRIMARY INSURED IS AGE OR LESS YOU MAY APPLY FOR A #HILD 4ERM ,IFE )NSURANCE 2IDER FOR )T INSURES THE PRIMARY INSURED´S CHILDREN AND STEP CHILDREN WHO ARE AGES DAYS THROUGH AGE AT THE TIME OF APPLICATION #HILDREN THEREAFTER BORN TO OR ADOPTED BY THE PRIMARY INSURED ARE COVERED DAYS AFTER BIRTH #OVERAGE CONTINUES TO AGE #OVERAGE TERMINATES AT THE PRIMARY INSURED´S AGE #OVERAGE ON A STEP CHILD CEASES UPON THE PRIMARY INSURED´S DIVORCE FROM THE STEP CHILD´S NATURAL OR ADOPTIVE PARENT )F THE PRIMARY INSURED DIES COVERAGE IS PAID UP TO THE EARLIER OF THE INSURED CHILD´S AGE OR THE #ONTRACT !NNIVERSARY $ATE ON WHICH THE PRIMARY INSURED´S !TTAINED !GE WOULD HAVE BEEN 5,#, #)2 )MPORTANT .OTICE 4HE INSURANCE PROCEEDS CASH VALUES AND LOAN VALUES WILL ALL BE REDUCED TO ZERO AND WILL NO LONGER BE PAYABLE IF 4EXAS ,IFE PAYS THE !CCELERATED $EATH "ENE½T 4HE BENE½T UNDER THIS RIDER IS INTENDED TO QUALIFY FOR FAVORABLE INCOME TAX TREATMENT UNDER THE )NTERNAL 2EVENUE #ODE OF )F THE BENE½T QUALI½ES FOR SUCH FAVORABLE TAX TREATMENT IT WILL BE EXCLUDABLE FROM YOUR INCOME AND NOT SUBJECT TO FEDERAL INCOME TAXATION 2ECEIPT OF THE BENE½T MAY AFFECT YOUR YOUR SPOUSE´S OR YOUR FAMILY´S ELIGIBILITY FOR -EDICAID !ID TO &AMILIES WITH $EPENDENT #HILDREN !&$# SUPPLEMENTARY SOCIAL SECURITY INCOME 33) AND DRUG ASSISTANCE PROGRAMS 4AX AND PUBLIC BENE½T LAWS RELATING TO ACCELERATION OF LIFE INSURANCE BENE½TS ARE COMPLEX 9OU SHOULD CONSULT A QUALI½ED TAX OR LEGAL ADVISOR OR SOCIAL SERVICES AGENCY TO DETERMINE HOW RECEIPT OF SUCH PAYMENT WILL AFFECT YOU AND YOUR FAMILY .EITHER 4EXAS ,IFE NOR ITS AGENTS ARE AUTHORIZED TO GIVE TAX OR LEGAL ADVICE )NTERIM )NSURANCE )NTERIM INSURANCE WILL BE IN FORCE ON THE APPLICATION DATE IF THESE CONDITIONS ARE MET THE INSURANCE IS PURCHASED THROUGH AUTOMATIC DEDUCTION THE DEDUCTION AUTHORIZATION IS SIGNED AND THE PROPOSED INSURED IS INSURABLE AT STANDARD RATES UNDER OUR RULES AND USUAL PRACTICE )NTERIM INSURANCE REMAINS IN EFFECT UNTIL THE EARLIER OF A THE 0OLICY $ATE B THE DATE WE DECLINE THE APPLICATION C THE DATE 7E NOTIFY THE APPLICANT THAT SHE IS INELIGIBLE FOR INTERIM INSURANCE OR D THE TH DAY AFTER THE APPLICATION DATE )N +ANSAS CLAUSES AND D DO NOT APPLY AND CLAUSES B AND C APPLY ONLY WHEN WE REFUND ALL PREMIUMS
4HIS IS A SUMMARY ONLY 0OLICY PROVISIONS PREVAIL 4HIS INFORMATION IS NOT A CONTRACT OR AN OFFER TO CONTRACT 0OLICY &ORM 02&.' .) ,IKE MOST LIFE INSURANCE POLICIES 4EXAS ,IFE POLICIES CONTAIN CERTAIN EXCLUSIONS LIMITATIONS EXCEPTIONS REDUCTIONS OF BENE½TS WAITING PERIODS AND TERMS FOR KEEPING THEM IN FORCE 0LEASE CONTACT A 4EXAS ,IFE REPRESENTATIVE FOR COSTS AND COMPLETE DETAILS
0OLICY &ORM 02&.' .) 3EE THE PURELIFE PLUS BROCHURE FOR DETAILS
monthly p r e m i u m s PureLife-plus
—
Standard Risk Table Premiums
—
Non-Tobacco
—
Express Issue GUARANTEED
Monthly Premiums for Life Insurance Face Amounts Shown
PERIOD
Age to Which Issue
Coverage is
Age
Guaranteed at
(ALB) 15D-10 11-16 17-20 21 22 23-25 26 27 28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
$10,000
14.80 16.10 17.70 19.30 20.90 22.30 23.30 24.00 24.80 25.80 27.30 29.60 32.40 35.50 39.60 42.50 45.30 47.80 50.40 53.20 56.20
$15,000
21.45 23.40 25.80 28.20 30.60 32.70 34.20 35.25 36.45 37.95 40.20 43.65 47.85 52.50 58.65 63.00
$20,000
28.10 30.70 33.90 37.10 40.30 43.10 45.10 46.50 48.10 50.10 53.10 57.70 63.30 69.50 77.70 83.50
$25,000 7.75 8.00 8.00 8.25 8.25 8.50 8.75 9.00 9.00 9.25 9.50 10.00 10.50 11.00 11.75 12.25 12.75 13.50 14.50 15.50 16.75 18.50 20.25 22.00 24.00 26.00 27.75 29.75 32.00 34.75 38.00 42.00 46.00 50.00 53.50 56.00 57.75 59.75 62.25 66.00 71.75 78.75 86.50 96.75 104.00
$30,000
$40,000
$50,000
$75,000
$100,000
9.30 9.60 9.60 9.90 10.20 10.50 10.50 10.80 11.10 11.70 12.30 12.90 13.80 14.40 15.00 15.90 17.10 18.30 19.80 21.90 24.00 26.10 28.50 30.90 33.00 35.40 38.10 41.40 45.30 50.10 54.90 59.70 63.90 66.90 69.00 71.40 74.40 78.90 85.80 94.20 103.50 115.80 124.50
11.90 12.30 12.30 12.70 13.10 13.50 13.50 13.90 14.30 15.10 15.90 16.70 17.90 18.70 19.50 20.70 22.30 23.90 25.90 28.70 31.50 34.30 37.50 40.70 43.50 46.70 50.30 54.70 59.90 66.30 72.70 79.10 84.70 88.70 91.50 94.70 98.70 104.70 113.90 125.10 137.50 153.90 165.50
14.50 15.00 15.00 15.50 16.00 16.50 16.50 17.00 17.50 18.50 19.50 20.50 22.00 23.00 24.00 25.50 27.50 29.50 32.00 35.50 39.00 42.50 46.50 50.50 54.00 58.00 62.50 68.00 74.50 82.50 90.50 98.50 105.50 110.50 114.00 118.00 123.00 130.50 142.00 156.00 171.50 192.00 206.50
21.00 21.75 21.75 22.50 23.25 24.00 24.00 24.75 25.50 27.00 28.50 30.00 32.25 33.75 35.25 37.50 40.50 43.50 47.25 52.50 57.75 63.00 69.00 75.00 80.25 86.25 93.00
27.50 28.50 28.50 29.50 30.50 31.50 31.50 32.50 33.50 35.50 37.50 39.50 42.50 44.50 46.50 49.50 53.50 57.50 62.50 69.50 76.50 83.50 91.50 99.50 106.50 114.50 123.50
Table Premium 75 70 66 66 65 63 63 63 62 62 60 61 62 62 64 64 64 65 66 67 68 70 72 73 74 75 76 77 78 79 80 82 83 85 86 85 84 84 84 84 85 87 89 93 94 95 96 96 96 95
PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.
Form: 10M014-rpltic EXP-B-M-1LO
41
monthly p r e m i u m s PureLife-plus
—
Standard Risk Table Premiums
—
Tobacco
—
Express Issue GUARANTEED
Monthly Premiums for Life Insurance Face Amounts Shown
PERIOD
Age to Which Issue
Coverage is
Age
Guaranteed at
(ALB) 15D-10 11-16 17-20 21 22 23-25 26 27 28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
$10,000
21.60 23.30 25.40 27.10 29.20 30.70 32.00 33.00 34.80 36.30 38.10 40.70 44.00 47.40 51.10 53.60 56.40 59.20 62.30 65.50 69.00
$15,000
31.65 34.20 37.35 39.90 43.05 45.30 47.25 48.75 51.45 53.70 56.40 60.30 65.25 70.35 75.90 79.65
$20,000
$25,000
$30,000
$40,000
$50,000
$75,000
$100,000
14.40 15.00 15.00 15.90 16.20 16.50 16.80 17.10 19.50 20.10 20.40 20.70 22.20 23.10 24.60 25.50 27.30 30.00 32.10 34.80 39.00 41.40 44.70 47.70 50.70 53.70 58.50 61.80 66.90 73.20 78.30 84.60 89.10 93.00 96.00 101.40 105.90 111.30 119.10 129.00 139.20 150.30 157.80
18.70 19.50 19.50 20.70 21.10 21.50 21.90 22.30 25.50 26.30 26.70 27.10 29.10 30.30 32.30 33.50 35.90 39.50 42.30 45.90 51.50 54.70 59.10 63.10 67.10 71.10 77.50 81.90 88.70 97.10 103.90 112.30 118.30 123.50 127.50 134.70 140.70 147.90 158.30 171.50 185.10 199.90 209.90
23.00 24.00 24.00 25.50 26.00 26.50 27.00 27.50 31.50 32.50 33.00 33.50 36.00 37.50 40.00 41.50 44.50 49.00 52.50 57.00 64.00 68.00 73.50 78.50 83.50 88.50 96.50 102.00 110.50 121.00 129.50 140.00 147.50 154.00 159.00 168.00 175.50 184.50 197.50 214.00 231.00 249.50 262.00
33.75 35.25 35.25 37.50 38.25 39.00 39.75 40.50 46.50 48.00 48.75 49.50 53.25 55.50 59.25 61.50 66.00 72.75 78.00 84.75 95.25 101.25 109.50 117.00 124.50 132.00 144.00
44.50 46.50 46.50 49.50 50.50 51.50 52.50 53.50 61.50 63.50 64.50 65.50 70.50 73.50 78.50 81.50 87.50 96.50 103.50 112.50 126.50 134.50 145.50 155.50 165.50 175.50 191.50
41.70 45.10 49.30 52.70 56.90 59.90 62.50 64.50 68.10 71.10 74.70 79.90 86.50 93.30 100.70 105.70
12.25 12.75 12.75 13.50 13.75 14.00 14.25 14.50 16.50 17.00 17.25 17.50 18.75 19.50 20.75 21.50 23.00 25.25 27.00 29.25 32.75 34.75 37.50 40.00 42.50 45.00 49.00 51.75 56.00 61.25 65.50 70.75 74.50 77.75 80.25 84.75 88.50 93.00 99.50 107.75 116.25 125.50 131.75
Table Premium
66 66 65 63 63 63 62 62 60 61 62 62 64 64 64 65 66 67 68 70 72 73 74 75 76 77 78 79 80 82 83 85 86 85 84 84 84 84 85 87 89 93 94 95 96 96 96 95
PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.
Form: 10M014-rpltic EXP-B-M-1LO
42
American Public Life Group Cancer (APL GC AP GC-3 5/1/06)- Sample for Mid-Texas Educator Benefit Co-Op Levels 1 & 2 - w/ Continuation Rider This coverage is offered on a guarantee issue basis. However, no benefits are payable for any loss during the first year of a Covered Person’s coverage as the result of a Pre-Existing Specified Disease. A Pre-Existing Specified Disease is defined as one for which, within twelve (12) months prior to the Covered Person’s effective date of coverage, medical advice, consultation, or treatment, including prescribed medications, was recommended or received from a member of the medical profession, or for which symptoms manifested ins such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment.
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Policy Benefit Highlights 5DGLDWLRQ7KHUDS\&KHPRWKHUDS\ Immunotherapy Benefit
U.S. Government / Charity Hospital / H.M.O. Benefit If an itemized list of services is not available because a Covered Person is: confined in a charity Hospital or U.S. Government owned Hospital; or covered under a Health Maintenance Organization (H.MO.) or a Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person, the Primary Insured may convert benefits to pay the indemnity amount shown. This benefit will be paid in lieu of most benefits under the policy.
Pays the indemnity amount when a Covered Person receives treatment and incurs a charge for covered therapy or covered drugs for Radiation Therapy, Chemotherapy, or Immunotherapy as defined in the policy. We will pay only one Radiation Therapy/Chemotherapy/Immunotherapy benefit per calendar month regardless of the number of treatments received during the month. This benefit does not cover other procedures related to Radiation Therapy/Chemotherapy/Immunotherapy. Anti-nausea drugs are not covered under this benefit. This benefit does not include any drugs/medicines covered under the Drugs and Medicine Benefit or the Hormone Therapy Benefit.
Drugs and Medicines Benefit Pays the indemnity amount for anti-nausea and pain medication prescribed by a Physician for a Covered Person for treatment of Cancer, who is also receiving Radiation Therapy / Chemotherapy/Immunotherapy, a covered surgery, or a Bone Marrow/Stem Cell Transplant. This benefit does not cover associated administrative processes. This benefit does not include drugs/medicines covered under the Radiation Therapy/Chemotherapy/ Immunotherapy Benefit or the Hormone Therapy Benefit.
Hormone Therapy Benefit Pays the indemnity amount for hormone therapy treatments as defined in the policy, prescribed by a Physician. This benefit covers drugs and medicines only and not associated administrative processes. This benefit does not include drugs/medicines covered under the Radiation Therapy/Chemotherapy/Immunotherapy Benefit or the Drugs and Medicine Benefit.
Blood, Plasma & Platelets Benefit Pays the indemnity amount for blood, plasma and platelets. This does not include any laboratory processes. Colony stimulating factors are not covered under this benefit. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit.
Surgical Benefit Pays an indemnity benefit up to the Maximum Per Operation amount shown in the Schedule of Benefits in the policy when a surgical operation is performed on a Covered Person for covered diagnosed Cancer, Skin Cancer, or reconstructive surgery due to Cancer. Benefits will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount shown in the Schedule of Benefits. Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone marrow surgeries are paid under the Bone Marrow Transplant Benefit. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis Benefit.
Transportation and Lodging Benefits & )DPLO\ Member Transportation and Lodging Benefits These benefits pay for transportation of a Covered Person and/or one adult family member, when the Covered Person has been diagnosed with Cancer and receives covered Radiation Therapy, Chemotherapy, Immunotherapy treatment, Bone Marrow/Stem Cell Transplant, or surgery due to Cancer in the nearest Physician prescribed Hospital providing such treatment that is at least 50 miles away from the Covered Person’s residence, using the most direct route. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Benefits will be provided for only one mode of transportation per round trip (maximum benefit of up to 1000 miles per round trip) and will be paid for up to 12 round trips per Calendar Year. Benefits for travel of the Covered Person and/or family member will be paid: once per Covered Person’s Hospital Confinement; or only on days of the Covered Person’s outpatient specialized treatment. Benefits for lodging of the Covered Person and/or family member will be paid: once per Covered Person’s Hospital Confinement; or only on days of the Covered Person’s outpatient specialized treatment. If the family member and the Covered Person travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging Benefit for the patient.
Anesthesia Benefit The Anesthesia benefit pays 25% of the amount paid for a covered surgery for the services of an anesthesiologist. Services of an anesthesiologist for bone marrow transplants, Skin Cancer, or surgical prosthesis implantation are not covered under this benefit.
2XWSDWLHQW+RVSLWDORU$PEXODWRU\6XUJLFDO Center Benefit Pays the indemnity amount shown towards the facility fee charges of an Ambulatory Surgical Center or Hospital for an outpatient surgical procedure of a diagnosed Cancer. Surgical procedures for Skin Cancer are not covered under this benefit.
Bone Marrow Benefit / Stem Cell Transplant Benefit Pays the indemnity amount when a bone marrow transplant or peripheral blood stem cell transplant is performed on a Covered Person as treatment for a diagnosed Cancer. This benefit will not be paid for the harvest of bone marrow or stem cells from a donor.
Hospital Confinement Benefit Pays the indemnity amount shown for a Covered Person while confined to a Hospital for at least 18 continuous hours for the treatment of a covered Cancer or the treatment of a condition or disease directly caused by Cancer or the treatment of Cancer. When the Covered Person’s Hospital Confinement continues for more than 90 days, this benefit will be paid in lieu of all other benefits payable for the Covered Person during such Hospital Confinement beginning on the 91st day. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.
This benefit is payable in or out of the Hospital.
Attending Physician Benefit Pays the indemnity amount for one Physician’s visit per day when a Covered Person requires the services of a Physician, other than a surgeon while Hospital Confined for the treatment of Cancer.
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Prosthesis Benefit and Hair Prosthesis Benefit
Dread Disease Benefit
Pays the indemnity amount for a surgically implanted prosthetic device received due to Cancer that manifested after the 30th day following the Effective Date, provided it was prescribed by a Physician as a direct result of surgery for Cancer. This benefit does not cover prosthetic related supplies. Temporary prosthetic devices used as tissue expanders are covered under the Surgical Benefit. Hair Prosthesis benefit pays the indemnity amount for a Covered Person’s hair prosthesis needed as a direct result of Cancer or the treatment of Cancer.
Pays the indemnity amount for each period of Hospital Confinement of a Covered Person for treatment of Dread Disease, as defined in the policy. Benefits for Dread Disease are ONLY provided under this provision of the policy.
Experimental Treatment Benefit Pays benefits for Experimental Treatment, as defined in the policy, the same as any other non-experimental treatment covered under this policy. This benefit does not provide coverage for treatments received outside of the United States or its Territories.
Second & Third Surgical Opinion Benefit Pays the indemnity amount once per diagnosis for a Covered Person’s second surgical opinion and if the second disagrees with the first, a third opinion, when the attending Physician recommends surgery for the treatment of Cancer. Surgical opinions for reconstructive, Skin Cancer, or prosthesis surgeries are not covered under this benefit.
Inpatient Special Nursing Services Benefit Pays the indemnity amount shown for full-time nursing care (other than that regularly furnished by a Hospital) while a Covered Person is Hospital Confined for treatment of Cancer. “Full-time” means at least eight consecutive hours during a 24-hour period. Care must be provided by a Nurse, as defined in this policy; be prescribed by a Physician; and be Medically Necessary for the treatment of Cancer.
Ambulance Benefit Pays the indemnity amount per trip for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and confined for at least 18 consecutive hours for treatment of Cancer.
Waiver of Premium Benefit If the Primary Insured becomes disabled due to Cancer and remains so for 90 continuous days, we will pay all premiums due after the 90th day so long as the Primary Insured remains disabled. “Disabled” means the Primary Insured’s inability because of Cancer: to work at any job for which (s)he is qualified by education, training, or experience; not working at any job for pay or benefits; and are under the care of a Physician for the treatment of Cancer. This policy must be in force at the time disability begins and the Primary Insured must be under age 65.
Extended Care Facility Benefit Pays the indemnity amount for each day room and board charges are incurred while a Covered Person is confined in an Extended Care Facility due to Cancer at the direction of a Physician that begins within 14 days after a covered Hospital Confinement. Paid for up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement.
Home Health Care Benefit Pays the indemnity amount for a Covered Person’s Home Health Care, as described in the policy, required due to Cancer when prescribed by a Physician in lieu of Hospital Confinement. This benefit does not include physical therapy or speech therapy. This benefit does not include: nutrition counseling; medical social services; medical supplies; prosthesis or orthopedic appliances; rental or purchase of durable medical equipment; drugs or medicine; child care; meals or house-keeping services. This benefit will be paid for up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. If the Covered Person qualifies for coverage under the Hospice Care Benefit, the Hospice Care Benefit will be paid in lieu of this benefit.
Hospice Care Benefit Pays the indemnity amount for Hospice Care directed by a licensed Hospice organization, as defined in the policy, of a Covered Person expected to live six months or less due to Cancer. This benefit does not include: well baby care; volunteer services; meals; housekeeping services; or family support after the death of the Covered Person.
Physical or Speech Therapy Benefit Pays the indemnity amount if a Physician advises a Covered Person to seek physical therapy or speech therapy. Physical or speech therapy must be performed by a caregiver licensed in physical or speech therapy and be needed as a result of Cancer or the treatment of Cancer. We will pay for one treatment per day up to four treatments per calendar month per Covered Person for any combination of physical or speech therapy up to a lifetime maximum of $1,000.
See the policy for more information regarding the benefits listed above.
45
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Diagnostic Testing Benefit Rider
This policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage.
We will pay the indemnity amount for one generally medically recognized internal Cancer screening test per Covered Person per Calendar Year. Screening test include, but are not limited to: mammogram; breast ultrasound; breast thermography; breast cancer blood test (CA 15-3); colon cancer blood test (CEA); prostate-specific antigen blood test (PSA); flexible sigmoidoscopy; colonoscopy; virtual colonoscopy; ovarian cancer blood test (CA-125); pap smear (lab test required); chest x-ray; hemocult stool specimen; serum protein electrophoresis (blood test for myeloma); Thin Prep Pap test. Screening tests payable under this benefit will ONLY be paid under this benefit. Benefits will only be paid for tests performed after the 30-day period following the Covered Person’s effective date of coverage.
If You are working either under contract to or as a Full Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us. Cancer means a disease which is manifested by autonomous growth (malignancy) in which there is uncontrolled growth, function, or spread (local or distant) of cells in any part of the body. This includes Cancer in situ and malignant tumors. It does not include other conditions which may be considered precancerous or having malignant potential such as: leukoplakia; hyperplasia; polycythemia; actinic keratosis; myelodysplastic and non-malignant myeloproliferative disorders; aplastic anemia; atypia; non-malignant monoclonal gamopathy; carcinoid; or pre-malignant lesions, benign tumors or polyps.
%DVH3ROLF\ All diagnosis of Cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. No benefits are payable for any Covered Person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A Pre-Existing Condition is a Cancer or Dread Disease for which, within 12 months prior to the Effective Date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any Covered Person has a Cancer or Dread Disease diagnosed before the end of the 30-day period immediately following the Covered Person’s Effective Date, coverage for that person will apply only to loss that is incurred after one year from the Effective Date of such person’s coverage. If any Covered Person is diagnosed as having a Cancer or Dread Disease during the 30-day period immediately following the Effective Date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the Schedule of Benefits in the policy.
&ULWLFDO,OOQHVV5LGHU Benefits will only be paid for a Covered Critical Illness as shown on the Policy/ Certificate Schedule page in the policy. No benefits will be provided for any loss caused by or resulting from: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; or alcoholism or drug addiction; or any act of war, whether declared or undeclared, or any act related to war; or military service for any country at war; or a Pre-Existing Condition; or a Covered Critical Illness when the Date of Diagnosis occurs during the Waiting Period; or participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; or participation in, or attempting to participate in a felony, riot or insurrection (A felony is as defined by the law of the jurisdiction in which the activity takes place). Internal Cancer does not include: other conditions that may be considered pre-cancerous or having malignant potential such as: acquired immune deficiency syndrome (AIDS); or actinic keratosis; or myelodysplastic and non-malignant myeloproliferative disorders; or aplastic anemia; or atypia; or non-malignant monoclonal gamopathy; or Leukoplakia; or Hyperplasia; or Carcinoid; or Polycythemia; or carcinoma in situ or any skin cancer other than invasive malignant melanoma into the dermis or deeper. For a Pre-Existing Condition no benefits are payable. Pre-Existing Condition, as used in this rider means any sickness or condition for which prior to the Effective Date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment.
+RVSLWDO,QWHQVLYH&DUH8QLW5LGHU No benefits will be provided during the first two years of this rider for Hospital Intensive Care Unit confinement caused by any heart condition when any heart condition was diagnosed or treated prior to the 30th day following the Covered Person’s Effective Date of this rider. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the Effective Date. No benefits will be provided if the loss results from: attempted suicide, whether sane or insane; or intentional selfinjury; or alcoholism or drug addiction; or any act of war, whether declared or undeclared, or any act related to war; or military service for any country at war. No benefits will be paid for confinements in units such as: Surgical Recovery Rooms, Progressive Care, Burn Units, Intermediate Care, Private Monitored Rooms, Observation Units, Telemetry Units or Psychiatric Units not involving intensive medical care; or other facilities which do not meet the standards for Intensive Care Unit as defined in the Rider. For a newborn child born within the ten-month period following the effective date of this rider, no benefits will be provided for Hospital Intensive Care Unit Confinement that begins within the first 30 days following the birth of such child.
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SUPPLEMENTAL ACCIDENT PLAN BENEFITS A-3, Accident Expense Policy Benefits
1 Unit
2 Units
3 Units
4 Units
Accidental Injury We will pay the actual charges per accident (not to exceed maximum benefits for units selected) for physician’s treatment, surgery, x-rays, reduction of fractures and dislocations or other emergency treatment expenses. In no case will the benefit exceed actual charges. There is a $50 deductible for emergency room expenses, per occurrence, regardless of the number of units. Expenses must commence within 60 days of the covered accident.
$500
$1,000
$1,500
$2,000
Ambulance Benefit We will pay the actual charges (not to exceed maximum benefits for units selected) for emergency transportation for covered treatment (ground or air ambulance). Such emergency transportation must occur within 21 calendar days of the covered accident.
$1,250
$2,500
$3,750
$5,000
Hospital Confinement We will pay the daily hospital benefit, based upon the number of units selected, when a covered insured is confined to a hospital due to accident or injury. This benefit begins the first day of confinement and pays a maximum of 30 days per any one accident.
$75
$150
$225
$300
Accidental Death Benefit* We will pay the benefit shown for accidental death which results within 90 days of the accident, based upon the number of units selected.
$5,000
$10,000
$15,000
$20,000
Dismemberment* We will pay the following benefit, based upon the number of units selected, for dismemberment which results within 90 days of a covered accident (dismemberment benefits are subject to a $5,000 per unit cumulative maximum per accident). Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs
$ 500 $ 500 $ 2,500 $ 5,000
$ 1,000 $ 1,000 $ 5,000 $10,000
$ 1,500 $ 1,500 $ 7,500 $15,000
$ 2,000 $ 2,000 $10,000 $20,000
Loss of Sight Benefit We will pay the benefit, based upon the number units selected shown, for the loss of sight due to accidental injury. Loss of sight in one eye Loss of sight in both eyes
$2,500 $5,000
$ 5,000 $10,000
$ 7,500 $15,000
$10,000 $20,000
Premiums Individual Individual and Spouse Individual and Children Family (2 parents and children)
$10.80 $19.40 $21.20 $29.80
$17.10 $29.80 $34.90 $47.60
$21.50 $38.90 $45.20 $62.60
$24.50 $44.90 $52.00 $72.40
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DEFINITIONS INJURY or ACCIDENTAL INJURY or ACCIDENTAL BODILY INJURY means physical damage to an Insured Person, sustained on or after the Effective Date, and while this Policy is in force, which is the direct cause of the loss, independent of disease, bodily infirmity or any other cause. All injuries sustained in any one accident and all complications arising therefrom and recurrence and complication shall be deemed to be a single “Injury.” DISABILITY means Your inability, as a result of covered Accidental Injury, to perform the substantial and material duties of Your occupation and You are not gainfully employed.
EXCLUSIONS AND LIMITATION Benefits otherwise provided by this policy will not be payable for services or expenses or any such loss resulting from or in connection with: 1. sickness, illness or bodily infirmity; except as covered by the Sickness Disability Rider; 2. suicide, attempted suicide or intentional self-inflicted injury, whether sane or insane; 3. dental care or treatment due to accidental injury to natural teeth; 4. war or any act of war (whether declared or undeclared) or participating in a riot or felony; 5. alcoholism or drug addiction; 6. travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare-paying passenger on a regularly scheduled airline; 7. injury originating prior to the effective date of the policy; 8. injury occurring while intoxicated (intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred); 9. voluntary inhalation of gas or fumes or taking of poison or asphyxiation; 10. voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a physician; 11. injury sustained or sickness which manifests itself while on full-time duty in the armed forces. Upon notice, the company will refund the proportion of unearned premium while in such forces; 12. injury incurred while engaged in an illegal occupation; 13. injury incurred while attempting to commit a felony or an assault; 14. mental or emotional disorders; 15. injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding parachuting or scuba diving; 16. driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; 17. charges incurred outside the U.S. if an insured traveled to the location for the purpose of receiving medical services, drugs or supplies; 18. hernia, carpal tunnel syndrome or any complication therefrom; 19. any bacterial infection (except pyogenic infections which shall occur with and through an accidental cut or wound). If you are entitled to benefits under this policy, as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any injury. These exclusions and limitations are not applicable for all states. Please refer to your policy or outline for applicable exclusions and limitations.
48
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COMBINED BENEFITS GROUP POBox164195
Austin,Texas78716
Office:512.261.6458TollFree:800.749.6458Fax:512.261.6975
CAFETERIA PLAN (SECTION 125) ENROLLMENT FORM
EMPLOYEE NAME__________________________________________________ THIS FORM MUST BE COMPLETED BY ALL EMPLOYEES WHO SIGN UP FOR HEALTH INSURANCE. The Trinity Charter School EMPLOYEE CAFETERIA PLAN (SECTION 125) makes it possible for you to pay for health insurance with pre-tax dollars and reduce your taxes. CAUTION! You cannot change this agreement during the plan year unless you have a significant change in family status: marriage or divorce; death; birth or adoption; loss or gain of a job; change in full-time or part-time status by participant or spouse; unpaid leave of absence; significant change in health coverage attributable to spouse’s employment. To allow the change, written notice of a family status change must be submitted within 31 days of the change. Example: If you sign up for yourself and child on insurance, you may not drop the child from insurance later in the plan year unless there is a change in family status, as listed above. PRE TAX ELECTION: ( ) I want to participate in the Trinity Charter School EMPLOYEE CAFETERIA PLAN (SECTION 125) and agree to pay for the following plan with pre-tax dollars: Health Insurance Employee Only Employee & Child(ren) Employee & Spouse Employee & Family
I understand that this deduction election is for health insurance premiums only. My election will remain in force during the entire plan year, September 1 through August 31, unless I have a change in family status as defined in the plan contract or I change my election during open enrollment. Date
Signature of Employee
Date
Signature of Employer
AFTER TAX ELECTION: ( ) I understand the Trinity Charter School EMPLOYEE CAFETERIA PLAN (SECTION 125) and choose not to participate in the plan: Date
Signature of Employee
Date
Signature of Employer 08/12
To: FULL-TIME BENEFIT EMPLOYEES Re: Special Enrollee Notification
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to inform you of your rights to Special Enrollment under this plan when you and or your eligible dependents decline coverage during the initial enrollment period or discontinue current coverage. If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself and/or your dependents in this plan provided that you request coverage within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption or a court order, you may be able to enroll yourself and/or your dependents, provided that you request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption or the court order. Employees who choose not to enroll when first eligible or do not meet the Special Enrollment criteria, will be considered Late Applicants. Late Applicants may apply for insurance only during the annual Open Enrollment period. I understand that to qualify as a Special Enrollee, I must notify the Plan Administrator within 31 days of: $
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Termination of my/our current coverage as a result of exhausting of the maximum period of COBRA coverage or due to legal separation, divorce, death or termination of employment or reduction in the number of hours of employment; or A change in my family status as a result of a marriage, birth, adoption or placement for adoption of a child.
Employee’s Signature:
Date: 08/14
General Notice of Special Enrollment Rights and Preexisting Condition Exclusion Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), your group health plan is required to provide you this notice explaining your group health plan’s procedures for your special enrollment rights and imposing preexisting condition exclusions. • Your Special Enrollment Rights – If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31days after the marriage, birth*, adoption, or placement for adoption. • Pre-existing Condition Exclusions – Under HIPAA, a “preexisting condition” is a condition for which medical advice, diagnosis, care, or treatment was recommended and received within the six-month period ending on the enrollment date in a health plan (the look-back period). Taking prescription medications during the look-back period constitutes receiving treatment. Your plan may deny benefits for a preexisting condition during a 12-month waiting period beginning on your enrollment date. (If you do not enroll in a timely manner, the maximum waiting period is 12 months from the date coverage begins.) A preexisting condition exclusion does not apply to a pregnancy or to a newborn child or adopted child under age 18 who becomes covered within 31 days of birth* or adoption. A genetic condition without advice, care, or treatment is not a preexisting condition. The existence of a preexisting condition will be determined using information obtained relating to an individual’s health status before his or her enrollment date. An individual’s enrollment date remains the same even if the individual changes benefit package options, as permitted by plan rules. The preexisting condition waiting period is reduced by any creditable coverage (prior coverage under various plans including, but not limited to, group health plans, individual health policies, Medicare, and Medicaid). You may obtain a certificate of creditable coverage from a prior plan sponsor or health insurance issuer. Should you disagree with the length of creditable coverage determined by TRS-ActiveCare, you have the right to appeal that determination and provide additional evidence of creditable coverage. For further information, contact your Benefits Administrator.
___________________________________ Employee Signature
____________________________ Date
*Special rules apply to newborns; refer to your TRS-ActiveCare Benefits booklet for more information.
