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www.elitebenefitsgroup.comELITEBENEFITSGROUPENHANCE - EDUCATE - ENGAGE - ENROLL - EMPOWER
Texas Property and Casualty Insurance Guaranty Association is committed to a comprehensive employeebenefitprogram that helps our employees stay healthy, feel secure andmaintain a work/life balance.The benefits program was designed to provide you with a competitive level of standard coverage while allowing you the flexibility to choose benefits that reflect your needs and personal circumstances. In addition to receiving coverage for health insurance, you have the opportunity to choose other coverage that best meets your needs.www.elitebenefitsgroup.com1
1. DEDUCTIBLEThe amount you must pay before your insurance company starts to pay for covered services each year.3. COPAYMENTSA fixed amount you pay for coveredservices such as doctor visit or diagnostic test.5. COVEREDSERVICESMedical services included in your insurance plan, such as doctor visits, hospital stays and diagnostic tests.7. OUT-OF-NETWORKA doctor or medical facility that is not contracted with your insurance company. Using out-of-network providers can result in you paying a higher portion of the medical bills or possibly the entire bill.2. COINSURANCEThe percentage of a medical expense you are responsible for paying. This usually kicks in after you have met your deductible.4. OUT-OF-POCKETMAXIMUMThe most you have to pay for covered services in a plan year.6. IN-NETWORKThe doctors, hospitals and other medical facilities and suppliers that contract with your insurance company to provide medical services.8. PROVIDERThe person or facility providing services to you, including doctors, hospitals and pharmacies.www.elitebenefitsgroup.comYOU SHOULD KNOW8TERMS 2
United Healthcare is our medical carrier. Below is a brief summary of the medical plan. Using In-Network facilities and physicians will result in significant cost savings to the member. Network facilities and physicians can be found at myuhc.com or call 1-877-797-8812. Please refer to the United Healthcare Summary of Benefits for a more comprehensive listing of services and additional information. www.elitebenefitsgroup.com1000 Deductible (Base Plan)IN NETWORKOUT OF NETWORKP1000i8022BParticipant80% 2%50%50%CaCaalelelndnddararYYeaear DeeDeductible (CYD)IndividualFamily$1,000$2,000$2,000$4,000Maximum mOuOt of PocoockeketIndividualFamily$3,000$6,000$8,000$16,000Office VisisititPrimary Care Visits (non-surgical)Specialist Visit (non-surgical)Urgent Care VisitPreventive CareRetailPPrerescscription*Preferred GenericEmployee Contribution per pay periodEmployee only Employee and Spouse Employee and Child (ren) Employee and Family$10 / $35 / $75 / $250 $61.82$179.33$342.87PlanHospitalIn-Patient ServicesOut-Patient ServicesEmergency Room$224.15MEDICAL INSURANCE $25 Copay$75 Copay$50 Copay Covered at 100%20% Coinsurance 20% Coinsurance 20% Coinsurance 50% after deductible50% after deductible 50% after deductible 50% after deductible50% after deductible 50% after deductible 20% after deductible$10 / $35 / $75 / $250 Download Summary of Benefits3
United Healthcare is our medical carrier. Below is a brief summary of the medical plan. Using In-Network facilities and physicians will result in significant cost savings to the member. Network facilities and physicians can be found at myuhc.com or call 1-877-797-8812. Please refer to the United Healthcare Summary of Benefits for a more comprehensive listing of services and additional information. www.elitebenefitsgroup.comNo Deductible (Buy-up Plan)IN NETWORKOUT OF NETWORKP0157521BParticipant100% %50%50%CaCaalelelndnddararYYeaear DeeDeductible (CYD)IndividualFamily$0.00$0.00$1,000$2,000Maximum mOuOt of PocoockeketIndividualFamily$4,000$8,000$8,000$16,000Office VisisititPrimary Care Visits (non-surgical)Specialist Visit (non-surgical)Urgent Care VisitPreventive CareRetailPPrerescscription*Preferred GenericEmployee Contribution per pay periodEmployee only Employee and Spouse Employee and Child (ren) Employee and Family$77.08$227.17$436.04PlanHospitalIn-Patient ServicesOut-Patient ServicesEmergency Room$284.41MEDICAL INSURANCE $15 Copay$15 Copay$75 Copay Covered at 100%No Charge, after $750 per occurrence copay. No Charge No Charge, after $300 per occurrence copay50% after deductible50% after deductible 50% after deductible 50% after deductible50% after deductible 50% after deductible No Charge, after $300 per occurrence copay $5 / $30 / $65 / $150 $5 / $30 / $65 / $150 Download Summary of Benefits4
P1000i8022B TPCIGA Monthly Subsidy EE Monthly Cost EE PPP Cost Employee Cost Humana Plan 2500 Employee Savings Per Month w/ UHC Employee Only $824.22 $700.59 $123.63 $61.82 $149.65 $26.02 Employee + Spouse $1,808.06 $1,359.76 $448.30 $224.15 $544.72 $96.42 Employee + Child(ren) $1,536.40 $1,177.75 $358.65 $179.33 $445.95 $87.30 Family $2,527.59 $1,841.84 $685.75 $342.87 $873.95 $188.20 P0157521B TPCIGA Monthly Subsidy EE Monthly Cost EE PPP Cost Employee Cost Humana Plan 1000 Employee Savings Per Month w/ UHC Employee Only $1,027.73 $873.57 $154.16 $77.08 $174.71 $20.55 Employee + Spouse $2,284.28 $1,715.46 $568.82 $284.41 $635.94 $67.12 Employee + Child(ren) $1,937.34 $1,483.01 $454.33 $227.17 $520.63 $66.30 Family $3,203.25 $2,331.17 $872.08 $436.04 $1,020.29 $148.21 5
DENTALwww.elitebenefitsgroup.comCLASSTYPE OF SERVICE INSURANCE PAYSNetworkOur national dental network offers more than 323,000 access points. Members may choose any dentist but may receive additional savings by choosing an in-network dentist. Plus, services not covered by this plan may also still be eligible for in-network savings. Out-of-network benefits are paid at the network negotiated rate.Colonial Life Dental insurance can help preserve your smile with easy-to-use coverage that promotes overall wellness. Benefits can help with a variety of dental costs, from routine cleanings to more advanced procedures. Additional benefits include, no annual rate increases, fully portable and national networks. Plan detailsThe benefit year maximum for this plan is $2,000 per person. Class A, B and C services apply toward the benefit year maximum.This plan has a deductible of $50 per person.Families only pay the deductible for a maximum of three people. Applies only to Class B and C Services.(Network: UNUM) $2,000, 100%80% 50%Class AClass BClass CPreventive ServicesBasic ServicesMajor Services100%80%50%The co-insurance for this plan is:6
Covered Procedures & Waiting PeriodsRoutine exams and cleanings (twice every 12 months)-One additional cleaning per 12 months if memberis in second or third trimester of pregnancy.X-rays-Bitewing X-rays (up to four films; once every 12 months)-Full mouth/panoramic x-rays (once every five years)Children’s services(up to age 14)-Fluoride treatment (once every 12 months)-Sealants (once every 36 months)-Space maintainers (up to age 14; once every 24 months)Adjunctive pre-diagnostic oral cancer screening (for age 40or older; once every 12 months).Simple restorative services (fillings) Simple extractionsEmergency treatmentRepair of crown, denture or bridgePreventive services (Class A): No waiting periodBasic services (Class B): No waiting periodMajor services (Class C):waiting period waived with prior dental. Oral surgery (extractions and impacted teeth)Anesthesia (subject to review; covered with complex oral surgery) Periodontics (gum treatments)Endodontics (root canals)Inlays and onlaysCrownsBridgesDenturesEndosteal implants (in lieu of an approved three-unit bridge)Employee Contributions per pay periodEmployeeEmployee and SpouseEmployee and Child (ren)Employee and Family$2.49$7.34$11.25$17.73www.elitebenefitsgroup.comOrthodontics: 12 month waiting periodAvailable for children up to age 19 $1,000 maximum lifetime benefit per child50% Coinsurance7
Vision coverage (VSP Network) can help you maintain healthy vision and overall wellness, as well as provide valuable financial protection for you, your spouse and dependent children.www.elitebenefitsgroup.comVISION BENEFITSIN-NETWORKOUT OF NETWORK ALLOWANCECO-PAYSSTANDARD PLASTIC LENSES (once per 12 months)FRAMES (once per 12 months)CONTACT LENSES (once per 12 months) (Includes fit, follow-up and materials) in lieu of eyeglass lenses and framesExam (once per 12 months)Materials lenses and Contact $10$10Up to $45See belowSingle visionBifocalTrifocalProgressive Covered by co-payCovered by co-payCovered by co-payUp to $30Up to $50Up to $65Up to $100 Frames available at provider locations$150 allowance then 20%Up to $70ElectiveMedically NecessaryCopay up to $150 allowanceCopay up to $210 allowanceUp to $105 allowanceUp to $210 allowanceVISIONNetwork- VSPCovered by co-payLenticular$55- $175*Optional contact fitting and evaluationUp to $60Employee Contributions per pay periodEmployeeEmployee and SpouseEmployee and Child (ren)Employee and Family$0.95$1.80$1.85$3.698
%(1(),76(/,*,%,/,7< $VDQHPSOR\HHRITPCIGA\RXKDYHDFFHVVWRWKHIROORZLQJEHQHILWVIRUWKH 3ODQ<HDU: January24±December14 Core Plan Benefits offered::+2,6(/,*,%/($1':+(1 $OODFWLYHIXOOWLPH(PSOR\HHVZKRZRUNDWOHDVW30KRXUVSHUZHHN(PSOR\HHEHQHILWV DUHHIIHFWLYHWKHILUVWRIWKHPRQWKIROORZLQJdate of hire(/,*,%/('(3(1'(176 <RXPD\HQUROO\RXUHOLJLEOHGHSHQGHQWVLQFRYHUDJH7KH\LQFOXGH-/HJDO6SRXVH-&KLOGUHQXSWRDJHUHJDUGOHVVRIVWXGHQWVWDWXVRUPDULWDOVWDWXVLQFOXGLQJQDWXUDOFKLOGUHQVWHSFKLOGUHQDQGOHJDOO\DGRSWHGFKLOGUHQLQFOXGLQJFKLOGUHQOLYLQJZLWK\RXEHIRUHWKHDGRSWLRQLVILQDOZKRDUH\RXUGHSHQGHQWVRUIRUZKRP\RXDUHUHTXLUHGWRSURYLGHKHDOWKFDUHFRYHUDJHXQGHUD4XDOLILHG0HGLFDO&KLOG6XSSRUW2UGHU&+$1*,1*<285&29(5$*('85,1*7+(<($5 ,I\RXQHHGWRFKDQJH\RXUFRYHUDJHWKURXJKRXWWKH\HDU\RXPD\RQO\GRVRLI\RX H[SHULHQFHDQHOLJLEOHFKDQJHLQVWDWXVOLIHHYHQWVXFKDV )PY[O(KVW[PVU *OHUNLPU0UZ\YHUJL*V]LYHNL(KKYLZZ,TWSV`TLU[:[H[\Z +LH[OPU[OL-HTPS` +LWLUKLU[*OPSK9LHJOLZ3PTP[PUN(NL +P]VYJL(UU\STLU[ -43(9LSH[LK3LH]L 3LNHS:LWHYH[PVU4HYYPHNL :WV\ZL3VZZVM6[OLY*V]LYHNL ,UYVSSTLU[PU4HYRL[WSHJL*V]LYHNL<RXPXVWsubmit a request of FKDQJHVWR\RXUEHQHILWFRYHUDJHto HR ZLWKLQGD\VRIDQHOLJLEOH FKDQJHLQVWDWXVOLIHHYHQW.ALL EMPLOYEES MUST EITHER WAIVE OR MAKE THEIR ELECTIONS DURING OPEN ENROLLMENT PERIOD.Otherwise you willneedWRZDLWXQWLOWKHQH[W$QQXDOOpen (QUROOPHQWwww.elitebenefitsgroup.com• United Healthcare• Dental• Vision• Supplemental (Voluntary) Benefits9
Compliance Notices Notice of Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). 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. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you are declining enrollment for yourself or your dependents (including your spouse) while coverage under Medicaid or a state Children’s Health Insurance Program (CHIP) is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ Medicaid or CHIP coverage ends. If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or a CHIP program with respect to coverage under this plan, you may be able to enroll yourself and your dependents (including your spouse) in this plan. However, you must request enrollment within 60 days after you or your dependents become eligible for the premium assistance. Women’s Health and Cancer Rights Act Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: •All stages of reconstruction of the breast on which the mastectomy was performed;•Surgery and reconstruction of the other breast to produce a symmetrical appearance;•Prostheses; and•Treatment of physical complications of the mastectomy, including lymphedema.These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, contact Humana at the member service number on your ID card. Newborns’ and Mothers’ Health Protection Act Notice Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). 10
Compliance Notices Michelle’s Law Notice Michelle’s Law was signed into law effective January 1, 2010. This law generally allows seriously ill or injured full time college students, who are covered under their parent’s health insurance plan, to take up to one year of medically necessary leave of absence if the leave normally would cause the dependent child to lose eligibility for coverage under the plan due to loss of student status. For the Michelle’s Law extension of eligibility to apply, a dependent child’s treating physician must provide written certification of medical necessity (i.e., certification that the dependent child suffers from a serious illness or injury that necessitates the leave of absence or other enrollment change that would otherwise cause loss of eligibility). *Under the Patient Protection and Affordable Care Act, group health plans are required to offer coverageto dependent children up to age 26, regardless of student status.Important Notice from TPCIGA About Your Prescription Drug Coverage and Medicare (CREDITABLE) Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with TPCIGA and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1.Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can getthis coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMOor PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.2.TPCIGA has determined that the prescription drug coverage offered by the Humana POS plans are, on averagefor all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and istherefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep thiscoverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Humana coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Humana coverage, be aware that you and your dependents will be able to get this coverage back. 11
Compliance Notices When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with TPCIGA and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information. Note: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through TPCIGA changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: •Visit www.medicare.gov•Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the“Medicare & You” handbook for their telephone number) for personalized help•Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1- 800-325-0778).12
The information in this Enrollment Guide is intended for illustrative purposes and informational purposes only. The information contained herein was taken from various summary plan descriptions, certificates of coverage and benefit information. Every effort was taken to accurately report your benefits however discrepancies and errors are always possible. It is not intended to alter or expand rights or liabilities set forth in the official plan documents or contracts. It is not an offer to contract nor are there any express or implied guarantees. In case of a discrepancy between this information and the actual plan documents, the actual plan documents will prevail. If you have any questions about this summary, please contact Human Resources or Elite Benefits GroupVISIONCONTACT INFORMATIONwww.elitebenefitsgroup.comHUMAN RESOURCESThathiana Bermudez512-345-9335ELITE BENEFITS GROUP713-575-3722www.colonialLifeDental.com 888-400-9304DENTAL www.vsp.com/eye-doctor800-877-7195United Healthcare myuhc.com or call 877-797-8812MEDICAL / PRESCIPTIONS13