2024-2025 Benefits Guide
`
1
2
What’s Inside ENROLLMENT ELIGIBILITY .................................................................................................. 4 BENEFIT CARRIER CONTACT INFORMATION ...................................................................... 8 MEDICAL PLANS............................................................................................................... 11 MEDICAL PLAN SUMMARY COMPARISON CHART............................................................ 12 VISION PLAN .................................................................................................................... 19 DENTAL PLAN................................................................................................................... 22 HEALTH REIMBURSEMENT ACCOUNT (HRA) .................................................................... 25 FLEX SPENDING ACCOUNTS (FSA) .................................................................................... 25 GROUP TERM LIFE INSURANCE ........................................................................................ 27 ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) COVERAGE ................................... 27 LIFE INSURANCE FEATURES.............................................................................................. 28 LONG-TERM DISABILITY (LTD) .......................................................................................... 29 OPTIONAL TERM LIFE INSURANCE ................................................................................... 29 WELLNESS ........................................................................................................................ 33 OPTIONAL BENEFITS ........................................................................................................ 36 LEAVE............................................................................................................................... 41 RETIREMENT .................................................................................................................... 41 TRAINING......................................................................................................................... 43 REQUIRED NOTICES ......................................................................................................... 44
3
ENROLLMENT ELIGIBILITY Employee Eligibility All active full-time employees are eligible for full benefits. Full-time is defined as employees who work more than 30 hours per week. Dependent Eligibility Dependents who meet the descriptions listed below are eligible for coverage. Full-time employees may elect medical, dental, and dependent life coverage for their dependents within 30 days of being hired. Current full-time employees may elect health care coverage for their dependents during the Open Enrollment period or within 30 days of experiencing a Qualifying Life Event. • Your spouse – the person to whom you are legally married. • Your child – your biological child, child with a qualified medical support order, legally adopted child, or child placed in the home for the purpose of applicable state and federal laws through the end of the month in which the child turns age 26. • Your stepchild – the child of your spouse for as long as you remain legally married to the child’s parent through the end of the month in which the child turns age 26. • Legal guardianship – a child for whom you have legal guardianship in accordance with an Order of Guardianship pursuant to applicable state or federal laws or a child for whom you are grant court-ordered temporary or other custody through the end of the month in which the child turns age 26. • Your adopted child – a child through adoption through the end of the month in which the child turns age 26. • Other Medical Support Order – a child in accordance with a Court Order pursuant to applicable state or federal laws. • Children over the age of 26 with permanent intellectual or physical disabilities if: o They were enrolled before they turned 26 and remain covered or they were over the age of 26 at the time of the enrollee’s initial enrollment; and o They are incapable of self-sustaining employment because of the intellectual or physical disability; and o They are dependent on the enrollee for care and financial support. How to Enroll in Benefits New hires will complete their benefit enrollment forms through the NEOGOV Onboarding portal and will also create an ADP account as first-time users to make benefit elections. Instructions will be emailed to new hires on how to register for ADP and make benefit elections. Current EAA employees will elect benefits via ADP during the annual Open Enrollment period. Instructions to make benefit elections will be emailed to employees prior to each annual Open Enrollment period. Employees are automatically enrolled in the following EAA plans and the required payroll deductions for TCDRS: • Basic Life & AD&D Insurance – no cost to the employee • Long Term Disability – no cost to the employee • Texas County District Retirement System (TCDRS) – 7% mandatory contribution Benefit elections become effective on the first of the month following date of hire. TCDRS becomes effective on date of hire.
4
Coverage Effective Dates The following effective dates apply provided the appropriate enrollment transaction (electronic or paper form) has been completed within the applicable enrollment period. Your coverage is effective for you and your dependent as follows: New Hire If you enroll within 30 days from date of hire, coverage for you and any dependents you enroll will be effective on the first of the month following date of hire. Annual Open Enrollment If you enroll during annual Open Enrollment, coverage for you and any dependents you enroll will be effective on the beginning of the plan year, October 1st. If you do not submit the appropriate enrollment forms during the required eligibility period of 30 days, you will have to wait until the next open enrollment period or experience a qualifying life event to make enrollment changes to your medical health plans. Coverage End Dates Coverage for you and your dependents will end on the earliest of the following: • The date the plan in question is terminated. • The last day of the month, in which you voluntarily terminate you or your dependents’ coverage. • The last day of the month in which you or your dependents no longer meet eligibility requirements. • The last day of the month your dependents no longer meet eligibility due to age. Waiving Coverage If you have medical coverage under another plan, youmay choose to decline (waive) the EAA’s medical plans. When an employee makes this choice, a “Declination of Coverage” form must be completed and returned to Human Resources. If you decide later that you would like coverage, you will not be able to enroll until the next Open Enrollment period or within 30 days of a qualifying life event. Some examples of other coverage could be: • Your spouse’s or parents’ plan • A government insurance program • An individual policy or other group coverage Qualifying Life Events A qualifying event is a life event that may allow an employee to add or drop coverage after being hired and outside of the Open Enrollment period. The change must be consistent with the event and documentation (i.e., marriage license, birth certificate, divorce decree, etc., ) must be provided to the HR Administrator within 30 days of the event. Please call or email the HR Administrator to schedule an appointment. You can add, drop or change coverage for yourself and your dependents when you experience a Qualifying Life Event such as: • Marriage • Divorce • Birth or adoption of a child
5
• Death • Child reaching age 26
• Child’s loss of eligibility on another plan • Spouse’s gain or loss of other coverage A child is terminated from medical and dental on the last day of the month he/she attains age 26. When a child gains or loses Children’s Health Insurance Program also known as CHIP, employees have 60 days to provide documentation of the gain or loss of coverage to make a corresponding change to their coverage (adding or dropping). If notification isn’t made to the HR Administrator within 30 days of the event, then employees must wait until the next Open Enrollment period. However, you must notify the HR Administrator to drop coverage for dependents who no longer meet eligibility requirements. Coverage effective dates for Qualifying Life Events Qualifying Event – Other than Birth/Adoption of Child If you enroll within 30 days of the qualifying life event, coverage for you and any dependents you enroll will be effective on the first day of the month following the date you submit the enrollment form. Qualifying Event – Birth/Placement/Adoption of Child If you enroll within 30 days of the date of birth, coverage will be effective on the date of birth; even if you have family coverage, you must complete an enrollment form. Premium is due for any period of dependent coverage if the dependent is subsequently enrolled, unless, specifically not allowed by applicable law. Additional premium may not be required when dependent coverage is already in force. If you enroll within 30 days of the court-ordered adoption, placement for adoption, guardianship or conservatorship of a child, coverage will be effective on the date of the adoption, placement for adoption, guardianship or conservatorship; even if you have family coverage, you must complete a Benefits Enrollment Form. Enrollment Tips • Have Social Security numbers, birth dates and required documentation to enroll your eligible dependents. • Choose your options carefully. Once you make an election as a new hire, during open enrollment or within the 30-day qualifying event window, you cannot cancel or change to another plan (i.e., switch your health insurance plan). Group insurance plan premiums are deducted from your paycheck before calculating payroll taxes. Because of these pretax tax savings, the IRS determines when you may make changes—either annually during open enrollment or during the plan year if you experience a qualifying life event. • Enroll online in ADP during open enrollment or within 30 days from your date of hire if you are a new employee. If you miss either of these enrollment deadlines, then you must wait until the next open enrollment period unless you experience another qualifying event during the year that allows you to make a change. • If you are hired during open enrollment and your benefits become effective prior to the new plan year, you will have to make new hire elections for the current year first, and then make open enrollment elections/changes for the next plan year.
• Medical benefit plans run from October 1st through September 30th. • Medical deductibles run from January 1st through December 31st.
6
Enrollment Form Errors It is your responsibility to ensure that information on your Benefits Enrollment Form is correct. If an error occurs, notify the Human Resources Administrator immediately. Premium Deduction Errors It is your responsibility to verify that the premium deductions taken from your paycheck are correct. Any deduction errors must be reported immediately to the HR Administrator. If an underpayment occurs, the EAA has the right
to collect any additional premiums owed. Human Resources Contact Information
Human Resources Representative Contact Information
Hilda Campos, Sr. HR Administrator (210) 477-8508
hcampos@edwardsaquifer.org
Raquel Garza, Sr. Director of HR
(210) 477-5137
rgarza@edwardsaquifer.org
7
BENEFIT CARRIER CONTACT INFORMATION Contact the HR Administrator for questions regarding insurance plans, premiums, eligibility or enrollment. For claims information, please contact the carriers below for assistance.
Provider/Plan
Contact Information
Website
(800) 521-2227 Claims Mailing Address: P.O Box 660044 Dallas, TX 75266-0044
MEDICAL Blue Cross Blue Shield Group# 326731 DENTAL Blue Cross Blue Shield VISION Blue Cross Blue Shield Group# 1023239
www.bxcbstx.com
(877) 442-4207
www.bxcbstx.com
(855) 556-8796
https://member.eyemedvisioncare.c om/bcbstx/en
LIFE INSURANCE Reliance Standard Life Insurance Company Life, AD&D, Vol Life Policy #GL161012 LTD Policy #LTD131287 HRA/FSA Proficient Benefit Solutions
(800) 351-7500 Claims Mailing Address: P.O. Box 7818 Philadelphia, PA 19101-7818 (210) 659-8100 (888) 659-8151 ask@proficientbenefits.com
www.rsli.com
www.proficientbenefits.com
RETIREMENT TCDRS Group# 448
Member Services (800) 823-7782
www.TCDRS.org
MissionSquare 457 Group #304645 IRA Group #701784 IRA Group #705239 RHS Group #801871
(800) 669-7400 Mailing Address: PO Box 96220 Washington, DC 20090
www.missionsq.org
401a Group #100069(MP) 401a Group #1000105 (PS)
Voluntary Benefits
AFLAC
(800) 992-3522 admin@canalichiogroup.com
www.aflac.com
Gold’s Gym
(210) 489-6239 or call any Gold’s Gym location directly (800) 654-7757 memberservices@legalshield.com
www.goldsgym.com
Legal Shield
www.legalshield.com
Peanut Butter Student Loan Program
support@getpeanutbutter.com
https://www.getpeanutbutter.com/
TransAmerica
(319) 355-8511 admin@canalichiogroup.com 800-891-2565 customercare@petbenefits.com
www.transamerica.com
Pet Benefit Solutions
https://www.petbenefits.com/land/e dwardsaquifer https://www.texastuitionpromisefun d.com/
Texas Tuition Promise Fund
1-800-445-4723
YMCA
(210)-246-9600 or call any YMCA location directly
www.ymcasatx.org
8
9
10
MEDICAL PLANS Medical coverage for full-time employees is provided through Blue Cross Blue Shield and there are two medical plan options to choose from, the Preferred Provider Organization (PPO) plan or the High Deductible Health Plan (HDHP). Each plan provides comprehensive major medical and prescription drug coverage as well as preventative care benefits and wellness programs. The premium rates for the medical plans being offered by the EAA are effective for the current plan year and run from October 1, 2024 through September 30, 2025. The EAA will pay 100% of the premium for the employee only cost on both plans. Employees may elect to add dependent coverage to their plan, however the cost associated with adding dependent coverage is to be paid for by the employee. The PPO plan is a Preferred Provider Organization plan that provides in and out of network coverage and has pre-set copays and deductibles. Once you meet your calendar year deductible, the plan will pay 70% coinsurance for in-network covered services while you pay 30%. For additional information regarding the various services, deductibles and copays, please refer to the Summary of Benefits located at the end of this booklet. PPO Plan Table I Biweekly Employee Cost Monthly Employee Cost Employee Only $0.00 $0.00 Employee + Spouse $436.34 $872.68 Employee + Child(ren) $337.01 $674.01 Employee + Family $773.49 $1,546.97
HDHP Plan
The HDHP is a high deductible health plan that provides in and out of network coverage. Services under this plan are paid 100% by the employee until the calendar year deductible has been met. Once the calendar year deductible has been met, the plan covers benefits at 100%. For additional information regarding the various
Biweekly Employee Cost
Monthly Employee Cost
Table II
Employee Only
$0.00
$0.00
Employee + Spouse
$297.21
$594.42 $459.10 $1,053.71
Employee + Child(ren) $229.55
Employee + Family
$526.86
services, deductibles and copays, please refer to the Summary of Benefits located at the end of this booklet. To compare the premium between the two plans and determine what your biweekly cost will be, see Tables I and II. These tables reflect what the biweekly and monthly costs are. Premiums for benefits are based on 24 pay periods annually. Employees who enroll in a medical plan will be automatically enrolled in a Health Reimbursement Arrangement (HRA) account. An HRA account is an employer-funded plan that reimburses employees for qualified medical expenses at no cost to employees. Depending on the plan that is selected, the EAA will contribute a set dollar
amount towards the employee’s Health Reimbursement Arrangement (HRA) account. For new hires, this contribution amount is prorated. The prorated amount is determined by the number of full months from an employee’s hire date to the remainder of the plan year. For example, if you are hired on July 5th and elect the PPO plan, then the HRA amount
HRA ANNUAL CONTRIBUTION
PPO Plan
$1,000.00 $3,499.99 $1,000.00 $500.00
HDHP Medical
HDHP Dental & Vision
HDHP FSA
will be 5/12th of the annual contribution ($1000/12 X 5 = 416.67). Employees enrolled in the PPO Plan will be enrolled in an HRA that can be applied to medical, dental and vision expenses. Employees enrolled in the HDHP plan will be enrolled in two separate HRA accounts. One account is exclusive to medical expenses and the other is only for dental and vision expenses. If enrolled in the HDHP plan, you will also receive an employer FSA contribution. For more info on FSA accounts, refer to page 17.
11
For a brief overview of the two plans, please see the following comparison chart. This chart will allow you to compare the two plans side by side. MEDICAL PLAN SUMMARY COMPARISON CHART The table below reflects an overview of some of the more common services used.
BCBS PPO
BCBS HDHP
OUT-OF- NETWORK
Services you may need Deductible Credit from Prior Credit Coinsurance Stop-loss Credit from Prior Carrier Calendar Year Deductible Individual
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
Yes
Yes
Yes
Yes
Yes
No
Yes
No
$5,000 $10,000
$14,700 $29,400
$6,000 $12,000
$12,000 $24,0000
Family
Coinsurance Stop-loss Maximum per cal. year Individual $5,600
Unlimited Unlimited
$6,000 $12.000
Unlimited Unlimited
Family
$14,700
Office Visits
Primary Care Physician
$45 copay $90 copay
100% after cal yr deductible
50% coinsurance
30% coinsurance
Specialist MD Live
$0 copay
Up to $48.00
Preventative care
Preventive Care/Screening (Routine Physicals)
No charge; deductible does not apply
No charge; deductible does not apply
50% coinsurance
30% coinsurance
Diagnostic Testing
No charge; deductible does not apply
No charge; deductible does not apply
X-Ray / Blood work
50% coinsurance
30% coinsurance
Other Diagnostic Procedures Imaging (CT/PET scans, MRIs)
100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible
30% coinsurance
50% coinsurance
30% coinsurance
Durable Medical Equipment
30% coinsurance
50% coinsurance
30% coinsurance
Physician/Surgeon Fees
30% coinsurance
50% coinsurance
30% coinsurance
Urgent Care
$75 copay
50% coinsurance
30% coinsurance
12
$500 copay plus 30% coinsurance
$500 copay plus 30% coinsurance
100% after cal yr deductible
100% after cal yr deductible
Emergency Room Care
Non-Emergency Situations (Preauthorization required) Facility Charges (Hospital room) 30% coinsurance
100% after cal yr deductible
50% coinsurance
30% coinsurance
Physician/Surgeon Charges
Emergency Medical Transportation
100% after cal yr deductible
100% after cal yr deductible
30% coinsurance
30% coinsurance
Facility Fee
Out-Patient Ambulatory Surgery Center In-Patient Hospital Room Extended Care Services Home Health Care
100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible
30% coinsurance
50% coinsurance
30% coinsurance
30% coinsurance
50% coinsurance
30% coinsurance
30% coinsurance
50% coinsurance
30% coinsurance
Skilled Nursing Facility
No Charge; deductible does not apply
Hospice Care
50% coinsurance
30% coinsurance
Mental Health/Behavior Health/ Substance Abuse Services Inpatient Services 30% coinsurance
50% coinsurance
30% coinsurance
Outpatient Services (Office Visits) All other outpatient services
$45 copay
50% coinsurance
30% coinsurance
30% coinsurance
50% coinsurance
30% coinsurance
13
Prescription Drug Coverage Retail Prescription (copays per 30-day supply) Preferred Generic Drugs Preferred $0 Non-Preferred $10
$10 plus 50% additional charge $20 plus 50% additional charge $70 plus 50% additional charge $120 plus 50% additional charge $150 plus 50% additional charge
Non-Preferred Generic Drugs Preferred Brand Drugs
Preferred $10 Non-Preferred $20 Preferred $50 Non-Preferred $70
No charge after deductible plus 50% additional charge
100% after cal yr deductible
Preferred $100 Non-Preferred $120
Non-Preferred Brand Drugs
Preferred Specialty Drugs Non-Preferred Specialty Drugs
$150 per Rx
$250 per Rx $250 plus 50% additional charge Mail Service Prescription (copays per 90-day supply) Deductible does not apply Preferred Generic Drugs No Charge
Non-Preferred Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs
$30 per Rx
100% after cal yr deductible
Not Applicable
Not Applicable
$150 per Rx
$300 per Rx More information about prescription drug coverage is available at https://www.bcbstx.com/rx-drugs/drug- lists/drug-lists
14
MEDICAL PLAN FEATURES Preferred Pharmacy Network
A Preferred Pharmacy Network is included in your prescription drug benefit plan. When you fill a prescription for up to a 30-day supply of a covered prescription drug from a retail pharmacy that contracts to participate in the Preferred Pharmacy Network, you may pay the lowest copay/coinsurance amount. If you fill a prescription at a non- preferred, in-network pharmacy, you may pay a higher copay or coinsurance. You can also fill a prescription for up to a 90-day supply of a covered prescription drug at a retail pharmacy that participates in the Preferred Pharmacy Network. To find a preferred pharmacy, sign in to myprime.com. Please note that changes may be made to the participating pharmacies in the future BCBS Top Preferred Pharmacies are: HEB, Walmart, Walgreens and Sam’s Club. IMPORTANT: CVS is out of the BCBS network . To find a new in-network pharmacy visit myprime.com and select “Find a Pharmacy” or call the Pharmacy Program number on the back of your member ID card. Once you find a new in-network pharmacy, you can easily transfer your prescriptions by doing one of the following: 1. Take your prescription bottle/bag to your new pharmacy. They can contact your current pharmacy to transfer your prescription. 2. Call your new pharmacy and ask them to contact your current pharmacy for your prescription information. 3. Ask your doctor to contact your new pharmacy with your prescription information. Moving to Home Delivery If you take any long-term medicine(s), consider using the PrimeMail home delivery service to help you save time and money. Up to a 90-day supply of your covered prescriptions can be shipped to you anywhere in the U.S., with free standard shipping. To choose home delivery:
1. Register and/or sign in to myprime.com. Click on “Fill with PrimeMail”. 2. Go to “Transfer to PrimeMail” and click on “Fill with PrimeMail”. You can also call PrimeMail at 800-423-1973 to transfer your prescription. Provider Finder Provider Finder from Blue Cross and Blue Shield of Texas (BCBSTX) is an innovative tool for helping you choose a provider, plus estimate, and manage health care costs. By logging in to Blue Access for MembersSM (BAM) you can use Provider Finder to: • Find a network primary care physician, specialist or hospital.
• Filter search results by doctor, specialty, ZIP code, language and gender – even get directions. • Estimate the cost of hundreds of procedures, treatments and tests and your out-of-pocket expenses. • Determine if Blue Distinction Center® (BDC), BDC+ or Blue Distinction Total Care is an option for treatment. • View patient feedback or add your review for a provider.
15
It’s easy to get started with Provider Finder by registering for Blue Access for Members (BAM): 1. Go to bcbstx.com. 2. Click the Log In tab, and then click the Register Now link. 3. Use the information on your BCBSTX ID card to complete the process. 4. Then, log in to BAM. Provider Finder is located under the Doctors & Hospitals tab. You can also call a BCBSTX Customer Service Advocate at the toll-free telephone number on the back of your member ID card for help in locating a provider. Get assistance while you are away from home. Text BCBSTXAPP to 33633 to get the BCBSTX App. The app lets you use BAM while you are on the go. You can stay connected to your claim’s activity, member ID card and coverage details – you can also receive prescription reminders and health tips via text messages.
Blue365 Discount Program Blue365 is just one more advantage you have by being a Blue Cross and Blue Shield of Texas (BCBSTX) member. With this program, you may save money on health and wellness products and services from top retailers not covered by
insurance. There are no claims to file and no referrals or preauthorization’s. Once you sign up for Blue365 at blue365deals.com/bcbstx, weekly “Featured Deals” will be emailed to you. These deals offer special savings for a short period of time. Below are some of the ongoing deals offered to Blue365 members. TruHearing® | Beltone™ | American Hearing Benefits - Members (and possibly their immediate family members) could get savings on hearing tests, evaluations and hearing aids. Jenny Craig® | Sun Basket | Nutrisystem® - Members can work toward reaching their weight loss goals with savings from leading programs. You may save on healthy meals, membership fees (where applicable), nutritional products and services. Fitbit® - You can customize your workout routines with Fitbit’s family of trackers and smartwatches that can be employed seamlessly with your lifestyle, your budget and your goals. Members receive a 20% discount on Fitbit devices plus free shipping. Reebok | SKECHERS® - Reebok, a trusted brand for more than 100 years, makes top athletic equipment for all people, from professional athletes to kids playing soccer. You can get 20% off select models. SKECHERS, an award- winning leader in the footwear industry, offers exclusive pricing on select men’s and women’s styles. You can get 30% off plus free shipping on their online orders. Livekick - Livekick is the future of private fitness. You can choose from training or yoga over live video with a private coach. You can get fit and feel healthier with action-packed 30-minute sessions that you can do from home, gym or hotel while traveling. You’ll also get a free two-week trial and 20% off a monthly plan on any Live Online Personal Training.
16
The Fitness Program The Fitness Program gives you flexible options to help you live a healthy lifestyle. As a Blue Cross and Blue Shield of Texas member, the Fitness Program is available exclusively to you and your covered dependents (age 16 and older). The program gives you access to a nationwide network of fitness locations. Choose one location close to home and one near work or visit locations while traveling. Other program perks include: • Flexible Gym Network: A choice of gym networks to fit your budget and preferences. • Studio Class Network: Boutique-style classes and specialty gyms with pay-as-you-go option and 30% off every 10th class. • Family Friendly: Expands gym network access to your covered dependents at a bundled price discount. • Convenient Payment: Monthly fees are paid via automatic credit card or bank account withdrawals. Blue365: EyeMed Vision Discount Program The EyeMed Vision Discount through Blue365 offers savings on eyeglasses, contact lenses, eye exams, accessories and laser vision correction. The EyeMed network consists of major national and regional retail locations, such as LENSCRAFTERS®, PEARLE VISION®, Target Optical®, Sears Optical® and JCPenney Optical, as well as independent ophthalmologists and optometrists. Additionally, you may go online to in-network providers at contactsdirect.com Visit eyemedexchange.com/blue365, click Find a Provider and begin your search. Be sure the Advantage network is selected. For more information about Blue365, log in to Blue Access for MembersSM (BAMSM) at bcbstx.com. Click the My Coverage tab at the top, and then click the Discounts link on the left. You do not need a referral. Simply visit any EyeMed provider and show your BCBSTX medical ID card. Note : This is not insurance. When contacting EyeMed or any retailer or provider in the EyeMed Advantage network, be sure to refer to the discount program. MD Live Virtual Visits
Getting sick after hours or on weekends used to mean a lengthy, costly trip to the emergency room or urgent care center. But with your virtual visits benefit, provided by Blue Cross and Blue Shield of Texas (BCBSTX) and powered by MDLIVE, the doctor is in 24/7/365. And you don’t have to leave the comfort of your own home. Virtual visits allow you to consult a doctor for non-emergency situations by phone, mobile app or online video anytime, anywhere. Speak to a doctor or schedule an appointment at a
time that works best for you. With virtual visits, you receive: • 24/7 access to an independently contracted, board-certified doctor • Access via online video, mobile app or telephone • If necessary, e-prescription sent to your local pharmacy
Virtual visits doctors can treat a variety of health conditions, including allergies, ear problems (age 12+), pink eye, asthma, fever (age 3+), rash, cold/flu, nausea, sinus infections and more. Also available is talk therapy which allows you to speak with a licensed counselor, therapist or psychiatrist for support with virtual visits, available by appointment. You can choose who you want to work with for issues such as anxiety, depression, trauma and loss or relationship problems.
17
24/7 Nurseline The 24/7 Nurseline from BCBS offers you access to speak to nurses anytime you need them. Their nurses can answer your questions and try to help you decide whether you should go to the emergency room, urgent care center, or make an appointment with your doctor. You can also call the 24/7 Nurseline whenever you or your covered family members need answers to health questions about asthma, headaches, cuts or burns, back pain, high fever, sore throat, diabetes, and much more. When you call, you can access an audio library of more than 1,000 health topics – from allergies to surgeries – with more than 500 topics available in Spanish. Call 800-581-0393 to reach the 24/7 Nurseline and talk to a nurse at any time. Wondr Health Wondr is a self-paced, online program that teaches you how to lose weight and improve your health without giving up your favorite foods. You'll get digital courses, an online dashboard, mobile app, social community, coaching support and more, all focused on helping you build new skills to have a healthy relationship with food and physical activity. It can also reduce your risk for serious conditions like diabetes and heart disease. Hinge Health Hinge Health is beneficial if you have chronic back, shoulder, neck, hip, or knee pain. Enhance your joint health and reduce pain in the comfort of your home. After enrolling, you'll receive a tablet pre-loaded with the Hinge Health app and wearable sensors that guide you through personalized exercises. A dedicated health coach is available to support you and answer any questions. This program is designed to help you build strength and return to your daily activities with less discomfort. Special Beginnings Special Beginnings is a confidential maternity program designed to help you better understand and manage your pregnancy. Get the support you need from early pregnancy until 6 weeks after delivery, including: • Pregnancy risk factor identification and ongoing communication/monitoring • Education material covering pregnancy and infant care topics, including a comprehensive educational book • Personal telephone contact with program staff • Assistance in managing high-risk conditions, such as gestational diabetes and preeclampsia
18
VISION PLAN The EAA offers voluntary vision insurance through Blue Cross Blue Shield of Texas. Our vision benefits plan gives you the freedom to choose any in-network provider with the option to pick out any frames, any lenses, and any contacts. With the right combination of retail and independent doctors, you will have access to providers with weekend and evening hours. Benefits can be applied online at Glasses.com—providing access to a huge selection of frames and lenses with 3-D virtual try-on technology. Please see the table below for a list of pricing for this voluntary pre-tax benefit. Dependent coverage is available to age 26.
For a complete list of in-network providers near you, visit eyemedvisioncare.com/bcbstx or call 1-855-556-8796. For LASIK providers, call 1-877-5LASER6
Vision Plan Biweekly Employee Cost
Monthly Employee Cost
Employee Only
$4.13 $7.84
$8.25 $15.67 $16.49 $24.25
Employee + Spouse
Employee + Child(ren) $8.25
Employee + Family
$12.13
Out-of-Network Reimbursement
Vision Care Service
In-Network Member Cost
FREQUENCY Examination
Once every 12 months Once every 12 months Once every 24 months
Lenses or contact lenses
Frame
Contact lens eval/fitting
N/A
VISION CARE SERVICES Exam with dilation as necessary Contact lens fit and follow up FRAMES Any available frame at provider location
$10 copay
Up to $30
Up to $40 for standard; 10% off retail price for premium
N/A
$0 Copay, $150 Allowance, 20% off balance over $150
Up to $75
STANDARD LENSES Single vision
$25 copay $25 copay $25copay $25 copay $90 copay
Up to $25 Up to $40 Up to $55 Up to $55 Up to $40 Up to $40
Bifocal Trifocal
Lenticular
Standard progressive lens Premium progressive lens LENS OPTIONS Tint (solid and gradient) Scratch resistant coating Polycarbonate lenses Ultraviolet coating Anti-reflective coating
See table on next page
$15
N/A
$0
Up to $5
$0 kids; $40 adults
Up to $5 KIDS
$15
N/A N/A N/A N/A N/A
See table on next page
High index lenses Polarized lenses
20% off retail 20% off retail
Photocromatic/transitions plastic
$75
19
Summary of Benefits continued
CONTACT LENSES (in lieu of spectacle lenses) Conventional
$0 copay, $150 Allowance, 15% off balance $0 copay, $150 Allowance, plus balance over $150
Up to $120 Up to $120
Disposable
Medically necessary
$0 copay, paid in full
Up to $210
OTHER Laser vision correction
15% retail price or 5% off promotional price
N/A
Additional pairs benefit
40% off purchase of complete pair of eyeglasses and a 15% off conventional contact lenses once the funded benefit has been used 40% off hearing exams and low price guarantee on discounted hearing aids 20% off non-covered items with limitations
N/A
Amplifon hearing discount
N/A
Additional discounts
N/A
Progressive price list
Member cost in-network
Standard progressive
$90 copay
Premium progressives as follows: Tier 1
$110 $120 $135
Tier 2 Tier 3 Tier 4
$90 copay, 80% of charge less $120 Allowance
Anti-reflective coating price list* Standard anti-reflective coating
Member cost in-network
$45
Premium anti-reflective coatings as follows: Tier 1
$57 $68
Tier 2 Tier 3
80% of charge
Other add-ons price list Photochromic (plastic)
Member cost in-network
$75
Polarized
80% of charge
For additional information regarding the various services and how often you may receive services, please refer to the Summary of Benefits located at the end of this booklet. Blue Cross and Blue Shield of Texas reserves the right to make changes to the products on each tier and the member’s out-of-pocket costs. *Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands.
20
Maximize Your Contacts Benefit With your vision benefit, you’re eligible for either contacts or lenses within the defined benefit frequency. If you use your benefit for contacts, you’re still eligible to use your frame benefit, too.
$130 frame allowance $10 lens copay $130 contact allowance
Sample vision plan
• You buy contacts (apply $130 contacts allowance) • You buy a pair of glasses (apply $130 frame allowance and 20% off any amount over, plus receive 20% off
Sample member transaction
How to Find a Vision Provider To find an in-network vision provider, create your account on the BCBS Vision Website. From your portal, you may: • Find an in-network eye doctor • Print or save a copy of your ID card • View special offers from various vision retailers • Use the personal estimator tool to estimate your cost prior to your appointment • View your claims and Explanation of Benefits • Access the Vision Wellness member site, which features vision wellness articles Hearing Care Enrolling in voluntary vision insurance will give you access to discounts on hearing aids through the Amplifon network. To find a provider in the Amplifon network, call 1-877-203-0675. International Vision Care A lot can happen when you travel overseas. If something happens to your eyewear, your vision benefits can help get your trip back in focus. • Emergency glasses delivered within 24 hours: get temporary glasses that adjust to your prescription. • The online Global Eyecare Guide provides step-by-step answers for country-specific vision questions. • Round-the-clock support: Speak to an agent or get free translation help in 160 languages — anytime. • Claims made easy: Upload receipts and get reimbursed 100% of remaining eligible out-of-network benefits. • Trusted providers in 20 countries: Easily find one with the online directory of international providers.
21
DENTAL PLAN
The EAA offers two dental insurance plan options through Blue Cross Blue Shield (BCBS). Both plans are PPO plans that can meet your needs; the difference is how out-of-network benefits are reimbursed. If you visit a dentist in the BCBS network, you will receive the most savings through either plan. To verify that your dentist is in network, visit the BCBS BlueCare Dental Provider website, where can search by dentist name, location, county, or center name. If your dentist is in-network, the 100/60 Plan offers higher coinsurance amounts, providing increased coverage. However, if your current dentist is NOT part of the BCBS network and you prefer NOT to change dentists, the 80/50 Plan reimburses up to the 90th percentile of the Usual, Customary, and Reasonable (UCR) rates, usually leading to higher reimbursements and lower out-of-pocket costs for out-of-network services. For a brief overview of the two plans, please see the following comparison chart. This chart will allow you to compare the two plans side by side. IMPORTANT: After selecting a plan, you cannot change your selection until the next Open Enrollment period. DENTAL PLAN COMPARISON CHART BCBS BlueCare Dental 100/60 Plan 80/50 Plan Program Basics Contracting Dentist/ Non-Contracting Dentist Contracting Dentist/ Non-Contracting Dentist Benefit Period Maximum $1,500 $1,500 Deductible $50 Individual/$150 Family $50 Individual/$150 Family
Out-of-Network Reimbursement
MAC
90th UCR
Covered Services Diagnostic Evaluations Periodic oral evaluations
100% (Deductible does not apply)
100% (Deductible does not apply)
Problem focused oral evaluations Comprehensive oral evaluations Preventive Services Prophylaxis (cleanings) Topical fluoride applications Diagnostic Radiographs Full-mouth and panoramic films
100% (Deductible does not apply)
100% (Deductible does not apply)
100% (Deductible does not apply)
100% (Deductible does not apply)
Bitewing films Periapical films
Miscellaneous Preventive Services Sealants Space maintainers
100% (Deductible does not apply)
100% (Deductible does not apply)
Basic Restorative Services Amalgams Resin-based composite restorations
100%
80%
Non-Surgical Extractions Removal of retained coronal remnants Removal of erupted tooth or exposed root
100%
80%
Non-Surgical Periodontal Services Periodontal scaling and root planing
100%
80%
Full-mouth debridement Periodontal maintenance procedures
22
Adjunctive Services Palliative treatment (emergency) Deep sedation / general anesthesia Endodontic Services Therapeutic pulpotomy and pulpal debridement Root canal therapy Apexification/recalcification Alveoloplasty and vestibuloplasty Excision of benign odontogenic tumor/cyst Excision of bone tissue Incision and drainage of an intraoral abscess Surgical Periodontal Services Gingivectomy or gingivoplasty and gingival flap procedures Clinical crown lengthening Osseous surgery Osseous grafts Soft tissue grafts/allografts Distal or proximal wedge procedure Major Restorative Services Single crown restorations Inlay/onlay restorations Labial veneer restorations Crowns placed over implants Prosthodontic Services Complete and removable partial dentures Denture reline/rebase procedures Fixed bridgework Prosthetics placed over implants Miscellaneous Restorative and Prosthodontic Services Prefabricated crowns Recementations Post and core, pin retention and crown/bridge repairs Adjustments Oral Surgery Services Surgical tooth extractions Implants
100%
80%
100%
80%
100%
80%
100%
80%
60%
50%
60%
50%
60%
50%
60%
50%
Orthodontic Services - Adult coverage and dependent children to age 19. Orthodontic Services Orthodontic Diagnostic Procedures and Treatment Lifetime Maximum per Participant 50% $1,500 (Deductible does not apply)
For additional information regarding the various services and how often you may receive services, please refer to the Summary of Benefits located at the end of this booklet.
23
Out-of-Network Coverage One of the differences between the two plans is how out-of-network expenses are covered. The 100/60 Plan reimburses out-of-network expenses based on the Maximum Allowable Charge (MAC), which is typically lower and may mean you pay more out-of-pocket. In contrast, the 80/60 Plan reimburses up to the 90th percentile of the Usual, Customary, and Reasonable (UCR) rates, usually resulting in higher reimbursements and lower out-of-pocket costs for out-of-network services. Therefore, if your dentist is in-network or you are open to finding a new in- network dentist, then the 100/60 plan offers higher coverages. Blue Care Dental Connection
As an enhanced service, Blue Cross and Blue Shield of Texas (BCBSTX) offers BlueCare Dental Connection. This service provides educational information and other resources to help you make choices about your dental care – at no extra cost. To help you learn about good oral health, BlueCare Dental Connection offers: • Educational mailings
• 24-hour online access to the Dental Wellness Center, which offers educational articles and special tools. To access the Dental Wellness Center, log in to Blue Access for Members at bcbstx.com and select the Wellness tab on the dashboard. Scroll down to the Dental Wellness Center section, and click the button. The Dental Wellness Center allows you to: • Ask dental questions through Ask a Dentist • Locate an in-network dentist using Find a Dentist • Research dental fees in your area with the Dental Cost Advisor • Search the Dental Dictionary for common dental terms • View videos on various dental topics in the Educational Videos section
Employee Bi-Weekly Cost
Premiums are the same for both plans. Employee- only dental coverage is provided at no cost to employees. However, if you choose to add dependents, you will be responsible for the additional premium costs. Please refer to the table on the left to view the monthly and bi-weekly costs.
Employee Monthly Cost
Dental Rates
Employee Only
$0.00
$0.00
Employee + Spouse Employee + Child(ren) Employee + Family
$29.65 $51.99 $93.23
$14.83 $26.00 $46.65
24
HEALTH REIMBURSEMENT ACCOUNT (HRA) The Health Reimbursement Arrangement (HRA) is administered through Proficient Benefits Solutions. An HRA is an employer sponsored benefit contributed 100% by the EAA and is designed to help offset medical expenses incurred by you. The HRA functions the same as an FSA plan. Even if you do not elect medical and dental coverage for your dependents, you can still utilize your HRA funds to cover their eligible expenses. The HRA contribution provided by the EAA is tied to the medical plan elected. Employees who elect the HDHP plan, are eligible to enroll in the medical HRA and a dental/vision HRA. Employees who elect the PPO plan, are only eligible to enroll in the Medical HRA.
Please refer to the table on the right for the annual maximum contribution. As mentioned, for new hires, this contribution amount is prorated. The prorated amount is determined by the number of full months from an employee’s hire date. For example, if you are hired on July 5th and elect the PPO plan, then the HRA amount will be 5/12th of the annual contribution ($1000/12 X 5 = $416.67). Amounts are also prorated for the dental/vision HRA.
HRA ANNUAL CONTRIBUTION January 1 PPO $1,000.00 HDHP Medical $3,499.99 HDHP Dental & Vision $1,000.00
You can receive reimbursement from your HRA for eligible medical, dental and vision expenses incurred by you or an eligible dependent during the current plan year, January 1 – December 31. HRA funds must be reimbursed during the plan year in which the expense was incurred. For example, expenses incurred in plan year 2025, must be reimbursed from funds during the same year (2025). Claims are processed by Proficient Benefit Solutions. You CANNOT cash the HRA annual contribution out and the funds must be spent on eligible expenses. Any money that is not used during the plan year will be rolled over for use in future years for medical expenses up to a maximum of $2,500. At the end of the plan year and allotted run-off period, any funds over $2,500 are rolled over to a Retirement Health Savings Account (RHS) in April of each year. For more information regarding an RHS, please see the RHS section of this booklet. For those enrolled in the PPO Plan, $2500.00 will be rolled into the HRA account for the following year. For those enrolled in the HDHP Plan, $1500.00 of the $2500.00 will be rolled into their Medical HRA account for the following year. The remaining $1000.00 will be rolled over into their Dental and Vision HRA account. Eligible Expenses HRA eligible expenses are the same as FSA eligible expenses. A list of HRA eligible expenses can be found here. HRA Run Off Period December 31st is the last day to incur claims for the 2024 plan year, and you must submit all claims by the end of the runoff period which runs January 1, 2025 to March 31, 2025. During this time, you can submit receipts and other documentation for eligible expenses incurred during the previous year (2024). FLEX SPENDING ACCOUNTS (FSA) A Flexible Spending Account (FSA) is a tax advantaged benefit plan administered by Proficient Benefit Solutions that allows employees to set aside portions of their salary to pay for their family’s health and/or daycare expenses. The amount set aside is not subject to payroll taxes. Flexible spending accounts contributions are based on the plan year (October 1, 2024 to September 30, 2025) election. IMPORTANT : You are not eligible to contribute towards a Medical FSA or be enrolled in the employer FSA, if you or your spouse have a Health Savings Account (HSA).
25
Medical FSA You can receive reimbursement from your Health Care FSA for eligible medical and dental expenses incurred by you or an eligible dependent using your pre-tax dollars. Claims will be processed through Proficient Benefits Solution. The maximum amount you may contribute to your Health Care FSA for plan year 2024-2025 is $3,200.00. Employees who enroll in the HDHP medical plan will receive FSA funds from the EAA and the amount
is pro-rated if you are a new hire. Please refer to the table on the right for the plan year amount. If you have funds remaining at the end of the plan year, a maximum of $640 will carry over to the next plan year while any funds in excess of $640 will be forfeited.
EAA FSA CONTRIBUTION
PPO
HDHP
October 1
N/A
$500.00
The entire annual amount is prefunded at the beginning of the plan year for immediate use on eligible expenses for current employees. Youmust enroll as a new hire for the FSA or enroll for the FSA every year during open enrollment or after a qualifying life event. The IRS publishes information on FSAs and eligible expenses on their website. If you have questions about an expense, please contact Proficient at (210) 659-8100. You may also view a list of eligible expenses on the Proficient Benefits Solution website. Dependent Care FSA A Dependent Care FSA offers an opportunity to save money on daycare expenses for eligible dependents. The maximum amount you may contribute to your Dependent Care FSA is $5,000 for individuals or married couples filing jointly or $2,500 for a married person filing separately. Also, the person whose daycare expenses you are claiming must satisfy the definition of a Tax Dependent, per IRS regulations. If you're a new hire enrolling mid-year, consider selecting a lower annual contribution amount initially, with the option to increase it during the next open enrollment period. For example, if you are hired in June and choose a $4,000 annual contribution amount, that amount will be divided by the number of payrolls remaining in the plan year (e.g., October to September). The resulting amount will be deducted from each paycheck. For instance, if you elect $4,000 and there are 7 pay periods left in the plan year, approximately $571.43 will be deducted from each paycheck. You can receive reimbursement from your Dependent Care FSA for expenses that have already been incurred and only up to the dollar amount that has already been deposited into your account. If you have funds remaining at the end of the plan year these funds will be forfeited. FSA Run Off Period September 30th is the last day to incur claims for the 2024-2025 plan year, and you must submit all claims by December 31, 2025. Reimbursement Process for FSA and HRA When you incur an eligible expense for you or your dependents, you may receive an email request to upload the Explanation of Benefits and/or receipts to your Proficient Portal or the Proficient Connect app. Claims are processed on a weekly basis and reimbursements are issued up to the available balance of your FSA and/or your Health Reimbursement Account. Monies will be reimbursed first from an employee’s FSA account then from the HRA account. To receive reimbursements for a covered expense under your health or dental coverage you must submit an itemized receipt or Explanation of Benefits (EOB) issued from the health and/or dental insurance plan. For all eligible expenses, you must submit documentation showing the following information:
26
Made with FlippingBook Digital Publishing Software