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MRIC I Region 17
Welcome We are pleased to offer a full benefits package to you and your eligible dependents. Read this guide to know what benefits are available to you. You may only enroll for or make changes to your benefits during Open Enrollment or when you have a Qualifying Life Event.
Availability Of Summary Health Information Your plan offers medical coverage options to help you make an informed choice, review each plan’s Summary of Benefits and Coverage (SBC) available by accessing www.txescbenefits.com.
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices for your prescription drug coverage. Please see the Important Legal Notices section for details.
Y O UR N EW B EN E FI T S
BEGIN A ND END
September 1, 2026 August 31, 2027
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Contents FLIP TO...
5 How to Enroll
HOW TO ENROLL
6 Enrollment FAQ
5
7 Eligibility 8 Qualifying Life Events 9 Medical Coverage 14 Health Care Options 15 Preventive Care
FREQUENTLY ASKED QUESTIONS
16 Health Savings Accounts
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18 Flexible Spending Accounts 20 FSA & HSA Comparison 21 Qualified FSA Expenses 22 Function Health
MEDICAL INSURANCE
24 Telemedicine
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25 Hospital Indemnity 26 Dental Coverage
27 Vision Coverage 28 Life and AD&D Insurance 30 Permanent Life Insurance 31 Educator Disability Insurance 33 Cancer Insurance 34 Accident Insurance 35 Critical Illness 36 Emergency Medical Transport 37 Identity Theft Protection
38 Glossary of Terms 42 Important Legal Notices
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Important Contacts MRIC BENEFITS Higginbotham Public Sector 833-870-2422 www.txescbenefits.com MRIC@hps.higginbotham.net
FLEXIBLE SPENDING ACCOUNTS National Benefit Services 800-274-0503 www.nbsbenefits.com
HOSPITAL INDEMNITY CHUBB Group #100000224 888-499-0425 educatorclaims@chubb.com
MEDICAL – TRS ACTIVECARE BCBSTX 866-355-5999 www.bcbstx.com/trsactivecare
HEALTH SAVINGS ACCOUNT HSABank (80) 357-6246 https://www.hsabank.com
CANCER CHUBB Group #100000224 888-499-0425 educatorclaims@chubb.com
TELEHEALTH Recuro 855-673-2876 www.recurohealth.com
LIFE AND AD&D Group #100000224 CHUBB 888-499-0425 educatorclaims@chubb.com
DENTAL Cigna Group #330940x8 800-244-6224 www.mycigna.com
INDIVIDUAL LIFE 5STAR Life Insurance 866-863-9753 www.5starlifeinsurance.com
VISION Superior Vision Group #27244-01/17 800-507-3800 www.superiorvision.com
DISABILITY The Hartford 855-547-9124 www.thehartford.com CRITICAL ILLNESS Lincoln Financial Group Group #CI0001067062 800-423-2735 www.lfg.com
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ACCIDENT Cigna Group #A11110861 800-244-6224 www.mycigna.com EMERGENCY MEDICAL TRANSPORTATION MASA 800-423-3226 www.masamts.com IDENTITY THEFT ID Watchdog 800-774-3772 www.idwatchdog.com
How to Enroll LOGIN PROCESS
1
Go to www.txescbenefits.com
2
Click Login.
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Enter your information: •Last name •Date of birth •Last four digits of your Social Security number Note: THEbenefitsHUB uses this information to check behind the scenes to confirm your employment status.
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Once confirmed, the Additional Security Verification page will list the contact options from your profile. Select either the Text, Email, Call, or Ask Admin options to receive a code to complete the final verification step.
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Enter the code that you receive and click Verify to begin your benefits enrollment.
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Enrollment FAQ Enrollment FAQs What if I miss the enrollment deadline?
When will I get my ID cards? If the medical carrier provides ID cards and there is a plan change, new cards usually arrive within four weeks of your effective date. If there are no plan changes, a new card may not be issued.
You may only enroll for or change your benefits during Open Enrollment or if you have a Qualifying Life Event. Is there an age limit for dependents to be covered under my benefits?
You may not need a card for dental and vision plans. Simply give your provider the insurance company’s name and phone number to verify benefits. You can also print a temporary card by visiting the insurance company’s website.
You may cover dependents up to age 26 on most benefit plans, but there are exceptions. See the Eligibility section for more details.
Where do I find benefit summaries and forms? Access www.txescbenefits.com and click on the benefit plan you need (i.e., Dental). Forms and benefits information are under the Benefits and Form section.
Benefit questions? Call 833-870-2422
How do I find an in-network provider? Access www.txescbenefits.com and click on the benefit plan for the provider you need to find. Click on the Quick Links section to find provider search links.
Email mric@hps.higginbotham.net
Important Limitations and Exclusions Information The following limitations and exclusions may apply when obtaining coverage as a married couple or for your dependents. Can I cover my family — a spouse or a dependent — as dependents on my benefits if we work for the same employer?
Some benefits may not allow you to do this if you work for the same employer. Review the applicable plan documents, contact Higginbotham Public Sector, or contact the insurance carrier for spouse and dependent eligibility. Are there FSA/HSA limitations for married couples? Yes, generally. Married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA-eligible – even if you would not use your spouse’s FSA to reimburse your expenses. However, there are some exceptions to the general limitation for specific types of FSAs. Contact the FSA and/or HSA provider before you enroll or reach out to your tax advisor for further guidance. Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and a Health Savings Account as a marri ed couple. You, the enrollee, shall hold harmless, defend, and indemnify Higginbotham Public Sector, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of your enrollment in spouse and/or dependent coverage, including enrollment in an FSA and HSA.
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Eligibility Who is Eligible for Benefits You are eligible for coverage if you are a regular, full-time employee. You may only enroll for coverage when: • You are a new hire
• It is Open Enrollment (OE) • You have a Qualifying Life Event (QLE) See Important Exclusions and Limitations section for details.
New Hire
Employee
Dependent(s)
Who is Eligible
Who is Eligible
Who is Eligible
• A regular, full-time employee working an average of 20 hours per week
• A regular, full-time employee working an average of 20 hours per week
• Your legal spouse
When to Enroll
When to Enroll
• Enroll by the deadline given by Human Resources
• Enroll during OE or when you have a QLE
When Coverage Starts
When Coverage Starts
• First of the month following the hire date or coincidental with the hire date
• You must be actively at work on the plan effective date for new benefits to be effective
• QLE: Ask Human Resources
Medical, Dental, Vision, Telehealth, Life Insurance and AD&D, Cancer, Hospital Indemnity, Critical Illness and Emergency Transportation
Flexible Spending Account
• Child(ren) over age 26 who are fully dependent on you for support due to a mental or physical disability and who are indicated as such on your federal tax return
When to Enroll • You must enroll the dependent(s) during OE or when you have a QLE • When covering dependents, you must enroll for and be on the same plans
MAXIMUM DEPENDENT ELIGIBILITY AGE BY PLAN Plan
• Child(ren) under age 26, regardless of student, dependency, or marital status
• Dependents cannot be double-covered by married spouses within the district as both employees and dependents
To Age
26
When Coverage Starts • Based on OE or QLE effective dates
26 (benefits terminate at the end of the plan year following the birthday)
About Your Coverage Effective Date You must be Actively at Work on the date your coverage becomes effective. Your coverage must be in effect for your spouse’s and eligible children’s coverage to take effect. See plan documents for specific details.
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Qualifying Life Events You may only change coverage during the plan year if you have a Qualifying Life Event, such as:
Marriage
Birth
Divorce
Adoption
Legal separation Annulment
Undergoing FMLA, COBRA event, court judgment, or decree
Placement for adoption
Becoming eligible for Medicare, Medicaid, or TRICARE
Change in benefits eligibility Death
Receiving a Qualified Medical Child Support Order
You have 30 days from the event to notify your Benefits Office and complete your changes. You may need to provide documents to verify the change.
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Gain or loss of benefits coverage Change in employment status affecting benefits
Medical Coverage Our medical plans protect you and your family from major financial hardship in the event of illness or injury. This health coverage provides benefits for a broad range of medical expenses that may be incurred on an inpatient or outpatient basis.
Medical Plan Contributions Monthly Premium TRS ActiveCare HD
Employee Only
$534.00
Employee + Spouse
$1,442.00
Employee + Children
$908.00
Employee + Family
$1,816.00 TRS Active Care 2
Employee Only
$1,013.00
Employee + Spouse
$2,402.00
Employee + Children
$1,507.00
Employee + Family
$2,841.00
TRS ActiveCare Primary Employee Only
$517.00
Employee + Spouse
$1,396.00
Employee + Children
$879.00
Employee + Family
$1,758.00
TRS ActiveCare Primary+
Employee Only
$607.00
Employee + Spouse
$1,579.00
Employee + Children
$1,032.00
Employee + Family
$2,004.00
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Health Care Options Becoming familiar with your options for medical care can save you time and money. HEALTH CARE PROVIDER
SYMPTOMS
AVERAGE COST
AVERAGE WAIT
$
2-5 minutes
$
15-20 minutes
$
15 minutes
$$
15-30 minutes
$$$$
4+ hours
$$$$$$
Minimal
Non-Emergency Care Access to care via phone, online video, or mobile app whether you are home, work, or traveling; medications can be prescribed
Telemedicine
24 hours a day, 7 days a week
Generally, the best place for routine preventive care; established relationship; able to treat based on medical history
Doctor’s Office
Rash Stomachache
Infections Sore and strep throat Vaccinations Minor injuries/sprains/ strains
Office hours vary
Usually lower out-of-pocket cost than urgent care; when you can’t see your doctor; located in stores and pharmacies
Retail Clinic
Allergies Cough/cold/flu
Hours vary based on store hours
Common infections Minor injuries Pregnancy tests Vaccinations
Sprains and strains When you need immediate attention; walk-in basis is usually accepted
Urgent Care
Generally includes evening, weekend and holiday hours
Minor broken bones Small cuts that may require stitches Minor burns and infections
Emergency Care Chest pain
Life-threatening or critical conditions; trauma treatment; multiple bills for doctor and facility
Hospital ER
24 hours a day, 7 days a week
Severe bleeding Blurred or sudden loss of vision Major broken bones
Services do not include trauma care; can look similar to an urgent care center, but medical bills may be 10 times higher
Freestanding ER
Difficulty breathing
24 hours a day, 7 days a week
Most major injuries
except trauma Severe pain
Note: Examples of symptoms are not inclusive of all health issues. Wait times described are only estimates. This information is not intended as medical advice. If you have questions, please call the phone number on the back of your medical ID card.
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Preventive Care Your benefits plan offers $0 preventive care for every age and sex. Preventive care is the care you receive to help prevent chronic illness or disease. It includes exams, lab work, screenings, immunizations, and counseling to prevent health problems, such as diabetes or heart disease. Visit https://www.healthcare.gov/co verage/p reventive-care-benefits for a full list.
Check Out All the Preventive Care You Can Get For $0! PREVENTIVE CARE COVERAGE INCLUDES Adults
Teens
Children
Cholesterol screening
Physical exam
Autism screening
Blood pressure screening
Blood tests for iron and cholesterol
Blood screening
Colorectal cancer screening
Anxiety screening
Depression screening
Lung cancer screening
Growth screening
Developmental screening
Hepatitis B screening
Hearing screening
Hearing screening
Well visits
Hepatitis B screening
Obesity screening and counseling
Bone density screenings
Depression screening
Hypothyroidism screening
Obesity screening
Sexually transmitted infection prevention
Behavioral assessments
Diabetes Type 2 screening
counseling
Well visits
Depression screening
Alcohol, tobacco, and drug use assessments
Immunizations
Mammograms
Tuberculosis screening
Dental cleanings
Cervical cancer screening
Immunizations
Oral health risk assessment
Immunizations
Dental cleaning and exams
Vision screening
Dental cleanings
Vision screening
Vision screening
Preventive Care FAQ Why should I get preventive care? Preventive care is the fastest and best way to uncover potential risks and avoid chronic health conditions.
Are all screenings, tests, and procedures covered under preventive care? No. Your doctor will be able to advise you as to the preventive care you need or should obtain, based on your medical and family history.
Why did I get a bill for preventive care? The insurance company has codes that must be met on the doctor’s bill for it to be processed as preventive and covered at 100 percent. If you have a medical complaint or your doctor finds a specific medical issue during your preventive care doctor’s visit, a diagnosis code for that issue or complaint will be on your bill. As a result, the insurance company may process the bill for a specific medical condition, not preventive care. In this case, you must pay the copay or portion of your deductible.
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Health Savings Account A Health Savings Account (HSA) is a tax-exempt tool to supplement your retirement savings and to cover current and future health costs. An HSA is a type of personal savings account that is always yours even if you change health plans or jobs. The money in your HSA (including interest and investment earnings) grows tax-free and spends tax-free if used to pay for current or future qualified medical expenses. There is no “use it or lose it” rule — you do not lose your money if you do not spend it in the calendar year — and there are no vesting requirements or forfeiture provisions. The account automatically rolls over year after year.
You Decide How To Use Your HSA Funds Use it Now
Let it Grow
• Make annual HSA contributions.
• Make annual HSA contributions.
• Pay for eligible medical costs.
• Pay for medical costs with other funds.
• Keep HSA funds in cash.
Watch and learn more!
• Invest HSA funds.
If you are age 55 or older, you may make a yearly catch-up contribution of up to $1,000 to your HSA. If you turn 55 at anytime during the plan year, you are eligible to make the catch-up contribution for the entire plan year.
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Health Savings Account Important HSA Information • Have your in-network doctor file your claims and use your HSA debit card to pay any balance due.
• You must keep ALL your records and receipts for HSA reimbursements in case of an IRS audit. • Only HSA accounts opened through our plan administrator are eligible for automatic payroll deduction.
HSA Eligibility You are eligible to open and contribute to an HSA if you are: • Enrolled in an HSA-eligible HDHP (ActiveCare HD) • Not covered by another plan that is not a qualified HDHP, such as your spouse’s health plan
• Not enrolled in a Health Care Flexible Spending Account • Not eligible to be claimed as a dependent on someone else’s tax return • Not enrolled in Medicare, Medicaid, or TRICARE
HSA contributions are taxdeductible and grow tax-deferred.
• Not receiving Veterans Administration benefits MAXIMUM HSA CONTRIBUTIONS 2026
2027 (Projected)
$4,400 Individual
$4,500 Individual
$8,750 Family
$8,950 Family
Withdrawals for qualifying medical expenses are tax-free.
Get More Information Find HSA vendor contact and full plan details at www.txescbenefits.com.
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Flexible Spending Accounts A Flexible Spending Account (FSA) allows you to set aside pretax dollars from each paycheck to pay for certain IRS-approved health and dependent care expenses.
Health Care FSA
Dependent Care FSA
The Health Care FSA covers qualified medical, dental, and vision expenses for you or your eligible dependents. Eligible expenses include:
The Dependent Care FSA (or Dependent Care Assistance Program – DCAP) helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full-time. You can use the account to pay for daycare or babysitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you (and your spouse, if married) must be gainfully employed, looking for work, a fulltime student, or incapable of self-care.
• Dental and vision expenses • Medical deductibles and coinsurance • Prescription copays
• Hearing aids and batteries You may not contribute to a Health Care FSA if you enrolled in a High-Deductible Health Plan (HDHP) and contribute to a Health Savings Account (HSA).
Dependent Care FSA Guidelines
How the Health Care FSA Works
• Overnight camps are not eligible for reimbursement (only day camps can be considered).
You can access the funds in your Health Care FSA two different ways:
• If your child turns 13 midyear, you may only request reimbursement for the part of the year when the child is under age 13.
• Use your FSA debit card to pay for qualified expenses, doctor visits, and prescription copays.
• You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care.
• Pay out-of-pocket and submit your receipts for reimbursement: » Visit my.nbsbenefits.com.
» Call 855-399-3035 for account balance.
• The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.
» Email service@nbsbenefits.com. » Fax 844-438-1496. » Mail 430 W. 7th Street, Suite 219393, St. Louis, MO 64105-1407.
ANNUAL MAXIMUM FSA CONTRIBUTIONS 2026
HEALTH CARE FSA
Maximum
$3,400
Carryover
$500
DEPENDENT CARE FSA $7,500 if filing jointly or head of household and $3,750 if married filing separately. No carryover — use it or lose it
You are entitled to the full election from day one of the plan year.
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Flexible Spending Accounts NBS Participant Portal and Mobile App To get the most out of your benefits, register for the NBS Participant Portal and/or download the app. On the portal and app, you can: • Access plan documents and account information.
• Update your personal information.
Watch and learn more!
• Look up qualified expenses. • Submit claims.
Questions?
• Check balances.
If you have any questions or concerns, contact the NBS Service Center:
• And more.
• Call 800-274-0503.
Visit http://my.nbsbenefits.com and click Register. Your employee ID is your Social Security Number.
• Email service@nbsbenefits.com.
Representatives are available Monday through Friday from 6:00 a.m. to 6:00 p.m. MST.
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HSA and FSA Comparison Knowing the difference between a Health Savings Account (HSA) and Health Care Flexible Spending Account (FSA) can help you choose the best option.
HEALTH CARE FLEXIBLE SPENDING ACCOUNT (FSA)
HEALTH SAVINGS ACCOUNT (HSA) •Acts as a personal savings account. •Funds can be used to pay for current or future health care expenses with pretax dollars; or funds can be saved for retirement. •Funds can also be used for your dependents, even if they are not covered by the HDHP.
Description
•HealthCare FSA: Use funds to pay qualified medical, dental, and vision expenses. •Limited Purpose HealthCare FSA: Use funds to pay qualified dental and vision expenses only. •Dependent Care FSA: Use funds to pay qualified dependent care expenses and services.
Contribution Source
Employee (You) and/or your employer
Employee (You) and/or your employer
Account Owner
Employee (You)
Employer
Underlying Insurance Requirement
High-Deductible Health Plan
None
2026 •HealthCare FSA: $3,400 •Limited Purpose HealthCare FSA: $3,400 •Dependent Care FSA: $7,500 (Single parent filing head of household, or married filing jointly) or $3,750 (Married filing separately)
2026 Maximum Contribution
Permissible Use of Funds
Year-to-year rollover of account balance?
•Individual: $4,400 •Family: $8,750 •Age 55+ Additional Catch Up $1,000
•Pay for qualified out-of-pocket medical, dental, and vision expenses. •If used on nonqualified expenses prior to age 65, subject to income tax plus a 20% penalty.
Yes. Funds roll over and can be used anytime or saved for future use.
See details in the Description box above.
2026 •HealthCare FSA: Allows for carryover of $680 to the next plan year OR an extended grace period after the end of the plan year (typically 2 ½ months) to spend remaining funds. •Limited Purpose HealthCare FSA: Same as HealthCare FSA •Dependent Care FSA: N/A
Does the account earn interest?
Yes
No
Portable?
Yes. It is always yours to keep, even if you change jobs or medical plans.
No
FLIP TO...
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HSA
19
FSA
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Qualified FSA & HSA Expenses
The products and services listed below are examples of medical expenses eligible for payment under your Health Care FSA. This list is not all-inclusive; additional expenses may qualify, and the items listed are subject to change in accordance with IRS regulations. Please refer to IRS Publication 502 Medical and Dental Expenses at www.irs.gov for a complete description of eligible medical and dental expenses.
Ab do mi na l s upp orts
Dia gn ostic fees
Ac up un ctu re
Eyeglasses
Am bu la nce
Gyne colo gist
Anesthetist
Hea lin g se rvices
Ar ch supp orts
He arin g ai ds an d batteries
Artificial limbs
Hos pita l bills
Bl oo d tests
Insuli n trea tmen t
Brac es
L ab tests
Cardi ogra phs
Meta bo li sm tests
Chi ro practor
Neurol ogist
Crutche s
Nurs ing
Den tal trea tmen t
Obstetric ian
Den tures
Ope ra tin g ro o m co sts
Ophth almolo gist/Optician / Optometrist
Derma tolog ist
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Ort ho p ed i c sh oes Ortho ped ist Oste op ath
Physici an Postnatal treatments Prena tal ca re Prescrip tion me dic ines Psychia trist Th era py eq ui pment
Whe elchair X-rays
Advanced Lab Tests and Health Screenings Get a deeper understanding of your body and spot potential issues early. Your benefit plan includes the opportunity for you and your family to enroll for a Function membership. Function empowers you to own your health through affordable access to advanced lab testing. A Function membership evaluates five times more biomarkers than the average physical, helping you gain a deeper understanding of what’s going on in your body, monitor for early indicators of disease, and track your health as it evolves. The membership includes: • Access to 100+ lab tests at the start of your membership. • Access to an additional 60+ midyear follow-up tests to track your progress. • Detailed clinician notes highlighting areas of focus. • A targeted action plan to help improve your health. • Results stored on one secure platform for easy access anytime.
HOW THE PROCESS WORKS After signing up for Function, you will get an email and text message to schedule a convenient time and location for your lab visit. Tests take less than 30 minutes and are done at one of more than 2,000 partner lab locations nationwide. You will then get a detailed summary of your results and a targeted action plan to help you reach your health goals. All results are stored in one secure location for you to access anytime. You can retest in six months to see how you are progressing. Nonroutine tests (e.g., advanced MRI, early detection of multiple cancers, allergies, heavy metals, and more) may be added for an additional cost.
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Advanced Lab Tests and Health Screenings Test More. Know More.
The cost for an individual annual membership* is $335!
Advanced testing across:
FSA/HSA ELIGIBLE
1.
Heart
Funds from your Flexible Spending Account (FSA) or Health Savings Account (HSA) may be used to pay for your membership. Reimbursement is not guaranteed, so please contact your FSA/HSA provider in advance to confirm the terms of reimbursement. If you do not have an FSA or HSA, use a personal credit card.
2.
Immunity
3.
Metabolics
4.
Hormones
5.
Nutrients
*Function membership includes prepaid access to 160+ lab tests each year at a Quest Diagnostics site. Due to state regulations, members testing in New York and New Jersey will be charged an additional fee directly by Quest for each lab visit. We cannot accommodate lab testing in Hawaii or Rhode Island at this time. You can schedule lab testing in a neighboring state.
6.
Heavy Metals
7.
Liver
8.
Kidneys
9.
Pancreas
10.
Prostate
11.
Sexual Health
12.
Electrolytes
13.
Thyroid
14.
Autoimmunity
15.
Urine
16.
Blood
How to Enroll Enroll anytime during the year. You will pay the membership fee(s) directly to Function. Visit https://www.functionhealth.com/aep/higginbotham.
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Telemedicine Registration is Easy Register today so you are ready to use this valuable service when and where you need it.
Your benefit coverage offers access to quality telehealth services. Connect anytime day or night with a board-certified doctor via your mobile device or computer for free or about the same cost as a visit to your regular doctor.
Visit www.recurohealth.com Call 844-979-0313
While telemedicine does not replace your primary care physician, it is a convenient and cost-effective option when you need care and:
Download the app to your mobile device
When to Use Telemedicine
• Have a non-emergency issue and are considering an after-hours health care clinic, urgent care clinic, or emergency room for treatment
Use telemedicine for minor conditions such as:
• Are on a business trip, vacation, or away from home • Are unable to see your primary care physician
• Sore throat
• Allergies
• Headache
• Fever
• Stomachache
• Urinary tract infections
• Cold
Behavioral Health
• Flu Do not use telemedicine for serious or lifethreatening emergencies.
Managing stress or life changes can be overwhelming, but it’s easier than ever to get help right in the comfort of your own home with Recuro. Visit a counselor or psychiatrist by phone, secure video, or on the Recuro app from your home, office, or on the go! Get affordable, confidential online therapy for a variety of counseling needs.
Employee Contributions Telehealth with BH for Family
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Hospital Indemnity Insurance The Hospital Cash plan helps you with the high cost of medical care by paying you a cash benefit when you have an inpatient hospital stay. Unlike traditional insurance which pays a benefit to the hospital or doctor, this plan pays you directly. It is up to you how you want to use the cash benefit. These costs may include meals, travel, childcare or eldercare, deductibles, coinsurance, medication, or time away from work.
Watch and learn more!
HOSPITAL INDEMNITY PLAN Low Plan
High Plan
Hospital Admission
$1,500 (maximum 3 per calendar year)
$3,000 (maximum 5 per calendar year)
Hospital Confinement
$100 per day (up to 30 days)
$200 per day (up to 30 days)
$500 (maximum 2 per year for less than 20 hours)
$500 (maximum 5 per year for less than 20 hours)
$3,000 (maximum 3 per calendar year)
$6,000 (maximum 3 per calendar year)
ICU Confinement
$200 per (day up to 30 days)
$400 per day (up to 30 days)
Newborn Care Stay
$500 per day (maximum 2 day stay)
$500 (maximum 2 day stay)
Employee Only
$20.36
$33.06
Employee and Spouse
$40.68
$73.38
Employee and Child(ren)
$29.68
$53.82
Employee and Family
$50.00
$81.18
Observation Unit Hospital ICU Admission
Employee Contributions
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Dental Coverage Our dental plan help you maintain good oral health through affordable options for preventive care, including regular checkups and other dental work.
Dental Benefits Summary CIGNA DENTAL PLAN
Policy Year Deductible • Individual • Family
DPPO Plan Two levels of benefits are available with the Dental Preferred Provider Organization (DPPO) plan: innetwork and out-of-network. You may select any dental provider for care, but you will pay less and get the highest level of benefits with in-network providers. You could pay more if you use an out-of-network provider.
Policy Year Benefit Maximum Per Individual
In-Network
Out-of-Network
$50 $150
$50 $150
$1,500
$1,500
You Pay
Reimbursement
Preventive Services Cleanings, X-rays, exams, fluoride treatments, space maintainers
$0
Any amount over Maximum Reimbursable Charge
Basic Services Fillings, general anesthesia, simple extractions
20%1
20%1
Major Services Crowns, endodontics, oral surgery
50%1
50%1
Orthodontia Dependent children to age 19
50%2
50%2
Employee Contributions
Find an In-Network Provider
Employee Only
$36.38
Visit https://hcpdirectory.cigna.com/.
Employee and Spouse
$64.20
Call 800-244-6224.
Employee and Child(ren)
$73.83
Employee and Family
$102.72
1
The amount you pay after the deductible is met
2
After Class IV deductible.
.
Class III Waiting Periods apply to Major Restorative and Orthodontia. Visit www.txescbenefits.com for full details.
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Vision Coverage Our vision plan offers quality care to help preserve your health and eyesight. Regular exams can detect certain medical issues such as diabetes and high cholesterol, in addition to vision and eye problems. You may seek care from any vision provider, but the plan will pay the highest level of benefits when you see in-network providers.
Vision Benefits Summary VISION PLAN Base Plan Lenses • Single vision • Lined bifocals • Lined trifocal
Frames Contacts In lieu or eyeglass lenses and frames • Lens fitting – standard Lens fitting – specialty • Contact lenses
Enhanced Plan
$0 $0 $0
Up to $26 Up to $34 Up to $50
$0 $0 $0
Up to $26 Up to $34 Up to $50
$130 retail allowance
Up to $52
$150 retail allowance
Up to $60
$0 $50 retail allowance $130 retail allowance
Not covered Not covered Up to $100
$0 $50 retail allowance $200 retail allowance
Not covered Not covered Up to $100
Benefit Frequency Exam
Once every 12 months
Lenses
Once every 12 months
Frames
Once every 12 months
Contacts
Once every 12 months
Employee Contributions Employee Only
$7.68
$11.24
Employee and Spouse
$15.37
$22.48
Employee and Child(ren)
$17.43
$25.66
Employee and Family
$26.93
$39.59
A full plan summary is available on your benefits website.
Find an In-Network Provider Visit www.superiorvision.com/locator. Call 800-507-3800. Watch and learn more!
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Life and AD&D Insurance Group term life is the least expensive way to buy life insurance. Life and Accidental Death and Dismemberment (AD&D) insurance is important to your financial security, especially if others depend on you for support or vice versa. With Life insurance, you or your beneficiary(ies) can use the coverage to pay off debts such as credit cards, loans, and bill s. AD&D coverage provides specific benefits if an accident causes bodily harm or loss (e.g., the loss of a hand, foot, or eye). If death occurs from an accident, 100% of the AD&D benefit would be paid to you or your beneficiary(ies).
Voluntary Life Insurance
Basic Life and AD&D Basic Life and AD&D insurance are provided at no cost to you.
Designating a Beneficiary A beneficiary is the person or entity you elect to receive the death benefits of your Life and AD&D insurance policies. You can name more than one beneficiary, and you can change beneficiaries at anytime. If you name more than one beneficiary, you must identify how much each beneficiary will receive (e.g., 50% or 25%). A full plan summary is available on your benefits website.
You may purchase additional Life and AD&D insurance for you and your eligible dependents. If you decline Voluntary Life and AD&D insurance when first eligible or if you elect coverage and wish to increase your benefit amount at a later date, Evidence of Insurability (EOI) – proof of good health – may be required before coverage is approved. You must elect Voluntary Life and AD&D coverage for yourself to elect coverage for your spouse or children. If you leave the company, you may be able to take the insurance with you. VOLUNTARY LIFE PER $10,000 Employee
• Increments of $10,000 up to 7 times basic annual earnings not to exceed $500,000 • New Hire Guaranteed Issue: $300,000
Spouse
• Increments of $5,000 up to 100% of the employee’s amount • New Hire Guaranteed Issue: $50,000
Child(ren)
• Birth to six months – $1,000 • Six months to age 26 – $10,000 • New Hire Guaranteed Issue: $10,000
Voluntary Life Rates per $10,000 Employee and Spouse
Age
(Spouse rates based on Employee age)
<29
$0.42
30-34
$0.68
35-39
$0.9
40-44
$1.38
45-49
$2.12
50-54
$3.24
55-59
$5.32
60-64
$7.79
65+
$15.2
Voluntary Life Rates for Child(ren) $5,000
$1.00
$10,000
$2.00
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Life and AD&D Insurance Employee Supplemental Life Coverage
Voluntary Accidental Death and Dismemberment
You may select more Life insurance for yourself. If you decline Supplemental Employee life insurance when first eligible or if you elect coverage and wish to increase your benefit amount at a later date, Evidence of Insurability (EOI) – proof of good health – may be required before coverage is approved.
You may select Voluntary Accidental Death and Dismemberment coverage. You must select coverage to select any Dependent coverage. VOLUNTARY AD&D PER $10,000 Employee
• Increments of $10,000 up a maximum of $500,000, not to exceed 10 times annual salary
Spouse
• Spouse amount is equal to 50% of amount elected by Employee
Child(ren)
• Child amount is equal to 10% of amount elected by Employee
EMPLOYEE SUPPLEMENTAL LIFE RATES $2.00
$30,000
$3.99
$45,000
$5.99
$60,000
$7.98
$75,000
$9.98
Dependent Supplemental Life Coverage
Voluntary AD&D Rates per $10,000 Employee + Family
$15,000
$0.28
You may select more Life insurance for your Spouse and Dependent(s) as outlined below. DEPENDENT SUPPLEMENTAL LIFE
Spouse
Under age 70 Dependent Child Live birth to under six months
Dependent Child Six months to age 26 Family Monthly premium cost
Option 1
Option 2
$5,000
$10,000
$1,000
$1,000
$1,000
$2,000
$1.33
$2.67
Watch and learn more!
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Permanent Life Insurance The Family Protection Plan Group Level Term Life Insurance from 5STAR Life Insurance helps protect your family.
Buy When You Are Young!
You do not have to elect coverage for yourself. You may elect coverage for: • Your spouse • Your financially independent children and grandchildren (14 days to age 26).
Buying life insurance when you are younger allows you to take advantage of lower premium rates while you are generally healthy. This allows you to buy more insurance coverage for the future and still pay less than you would if you were older and trying to buy the same coverage amount. This is especially important if you have dependents who rely on your income, or you have debt that would need to be paid off.
Coverage lasts until age 121 for all insured, so your family can be protected into their retirement years as long as your premiums are paid.
This coverage is portable, which means you may continue with no loss of benefits or increase in cost if you terminate employment after the first premium is paid. You will simply be billed directly.
File a Claim
Individual Life Advantages • • • • •
Contact 5Star directly at 866-863-9753.
Customizable for you and your family Terminal Illness Acceleration of Benefits Portable Family Protection Quality of Life Benefit Acceleration (not available for children or at ages 66-70)
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Educator Disability Insurance Disability insurance provides partial income protection if you are unable to work due to a covered accident or illness for an extended period of time. Educator Disability insurance is a hybrid that combines features of Short Term Disability and Long Term Disability into one plan. This insurance provides partial income protection if you are unable to work due to a covered accident or illness. The plan gives you flexibility to be able to choose an amount of coverage and a waiting period that best meets your needs.
Educator Disability FAQ Are there pre-existing condition limitations? Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless:
EDUCATOR DISABILITY Benefits Begin After • 0/7 • 14/14 • 30/30 • 60/60 • 90/90 • 180/180
Percentage of Earnings You Receive
Plan A
Plan B
$3.08 $2.28 $2.04 $1.39 $1.20 $0.93
$2.90 $2.29 $1.92 $1.31 $1.14 $0.87
• You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or • You have been insured under this policy for 12 months before your disability begins. If your disability is a result of a pre-existing condition, we will pay benefits for a maximum of 4 weeks.
$100 increments between $200 and $10,000 (cannot exceed 66 2/3% of your current monthly earnings)
Maximum Monthly Benefit
$10,000
Maximum Benefit Period
Varies; See plan documents.
When do disability benefits begin? The start of your disability insurance depends on the specifics of your policy and your disability. Benefits usually begin after a pre-determined waiting period (such as 90 to 180 days from the onset of the disability).
Will I get all of my disability benefit? Your benefit may be reduced by other income you receive or are eligible to receive due to your disability, such as Social Security Disability insurance, Workers’ Compensation, unemployment benefits, and State Teacher Retirement Disability Plans. How long will the disability benefits last?
This varies due to the age at which the disability occurs, and the schedule selected. Refer to your plan documents for full details.
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Educator Disability Insurance What is the best way to choose which disability plan option to enroll in? Your disability plan selection should be a two-step approach. Step One
Step Two
Choose your elimination period or waiting period. This is how long you are disabled and unable to work before your benefit will begin. It will be displayed as two numbers, such as 0/7, 14/14, 60/60, etc.
Choose your benefit amount. This is the maximum amount of money you would get from the carrier on a monthly basis once your disability claim is approved by the carrier.
The first number indicates the number of days you must be disabled due to Injury and the second number indicates the number of days you must be disabled due to Sickness.
When choosing your monthly benefit, consider how much money you need to pay your monthly bills. Choose your monthly benefit amount based on your answer.
When choosing your elimination period, determine how long you could go without a paycheck. Choose your elimination period based on your answer.
File a Claim Visit www.txescbenefits.com. Call 866-278-2655 (Group #395331).
Note: Some plans will waive the elimination period if you choose 30/30 or less and you are confined as an inpatient to the hospital for a specific time period. Review your plan details to see if this feature is available to you.
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Cancer Insurance Treatment for cancer is often lengthy and expensive. While your health insurance helps pay the medical expenses for cancer treatment, it does not cover the cost of non-medical expenses, such as out-of-town treatments, special diets, daily living, and household upkeep. In addition to non-medical expenses, you must pay your health plan deductibles and/or coinsurance. Cancer insurance helps pay for these direct and indirect treatment costs so you can focus on your health. Exclusions and limitations apply. CANCER INSURANCE Low Plan
High Plan
$5,000 $7,500 child(ren)
$10,000 $15.000 child(ren)
$10,000
$20,000
$100 per day Maximum days per confinement: 31
$200 per day Maximum days per confinement: 31
$9,000
$9,000
Employee Only
$16.18
$24.16
Employee and Spouse
$30.80
$45.98
Employee and Child(ren)
$19.96
$29.58
Employee and Family
$35.48
$48.72
Cancer Diagnosis Internal Cancer First Diagnosis Radiation and Chemotherapy Per covered individual per calendar year
Hospital Confinement Bone Marrow Transplant Maximum per lifetime
File a Claim Visit educatorclaims@chubb.com Call 888-499-0425.
Employee Contributions
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Accident Insurance Accident insurance provides affordable protection against a sudden, unforeseen accident. The Accident plan helps offset the direct and indirect expenses resulting from an accident such as copayments, deductible, ambulance, physical therapy, childcare, rent, and other costs not covered by traditional health plans. See the plan document for full details. ACCIDENT INSURANCE
Benefit Ambulance Ground/Air
$500/$2,000
Emergency Room
$400
Hospital Admission
$1,500
Confinement • Hospital • ICU
$400 per day $600 day
Specific Sum Injuries Dislocations, ruptured discs, eye injuries, fractures, lacerations, concussions, and more
$50-$20,000
Loss • Accidental Death • Dismemberment 1
Up to $75,000
Sports Accident Benefit Organized or personal sports activity – 10 per year max
Up to $20,000
50% of the qualified benefit
Employee Contributions
1
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Employee Only
$7.79
Employee and Spouse
$14.54
Employee and Child(ren)
$19.39
Employee and Family
$26.13
Percentage of benefit paid for dismemberment is dependent on type of loss.
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Critical Illness Insurance Critical Illness insurance helps pay the cost of non-medical expenses related to a covered critical illness or cancer. The plan provides a lump sum benefit payment to you upon first and second diagnosis of any covered critical illness or cancer. The benefit can help cover expenses such as lost income, out-of- town treatments, special diets, daily living, and household upkeep costs. This coverage is portable. See the plan document for full details.
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CRITICAL ILLNESS INSURANCE Employee
$10,000; $20,000; or $30,000
Spouse & Children
$10,000; $20,000; or $30,000 up to 100% of the employee coverage amount
Health Assessment / Wellness Benefit
$50 per year
First Occurrence Benefit Full Coverage Benign brain tumor, invasive cancer, coma, loss of speech, loss of hearing, loss of sight, heart attack, kidney failure, major organ transplant, ALS, Alzheimer’s disease, multiple sclerosis, advanced Parkinson’s disease, severe burns, stroke
Partial Coverage Transient ischemic attacks, coronary artery obstruction, carcinoma in situ Childhood Diseases Cerebral palsy, cleft lip/palate, cystic fibrosis, Type 1 diabetes, Down Syndrome, spina bifida, muscular dystrophy
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100% of benefit amount
10%-25% of benefit amount
100% of benefit amount
Emergency Medical Transport Did you know that a ground ambulance ride can cost more than $1,200 and an air ambulance ride can cost up to $70,000? If you or a family member is in need of an emergency medical transport, your insurance coverage and Medicare may not cover all of the costs.
For More Details Visit www.masamts.com. Call 800-423-3226 for assistance. Call 800-643-9023 for claims. Emergency Transport Services
Consider buying emergency transport services to greatly reduce or completely cover the cost of emergency transportation. After your medical crisis, contact MASA MTS to negotiate with your medical plan provider and cover the balance on your medical transportation bills.
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Emergent Plus
Platinum Plan
Emergency Air Transportation
x
x
Emergent Ground Transportation
x
x
Non-Emergency InterFacility Transportation
x
x
Repatriation/ Recuperation
x
x
Escort Transportation
x
Visitor Transportation
x
Return Transportation
x
Mortal Remains Transportation
x
Minor Return
x
Organ Retrieval/Organ Recipient Transportation
x
Vehicle Return
x
Pet Return
x
Worldwide Coverage
x
Employee Contributions Employee and Family
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$14.00
$39.00
ID Theft Protection IDENTITY THEFT PROTECTION OPTIONS
Identity theft is one of the fastest-growing crimes in the country. Millions of people have their identity stolen each year. Protect yourself and restore your identity with coverage that includes:
1B
Platinum
Credit Reports and VantageScore Credit Scores
1 Bureau Monthly
1 Bureau Daily and 3 Bureaus Annually
Credit Score Tracker
1 Bureau Daily
1 Bureau Daily
• Identity consultation and advice
• Dark web monitoring
Credit Report Monitoring
1 Bureau
3 Bureaus
• Threat and credit alerts
Credit Report Lock
1 Bureau
Multi-Bureaus
• Licensed private investigators
• 24/7 emergency ID protection access
Identity Theft Insurance
Up to $1M
Up to $1M
• Identity and credit monitoring • Social media monitoring
• Mobile app
• Identity restoration
• And more!
401k/HSA Stolen Funds Reimbursement
Up to $500,000
ID Theft Protection Rates
1B
Platinum
Employee Only
$7.95
$11.95
Employee and Family
$14.95
$22.95
• Credit freeze assistance
For More Information Visit www.idwatchdog.com.
Watch and learn more!
Call 800-774-3772.
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Glossary of Terms ACA (Affordable Care Act) – The ACA is comprehensive your share of the cost of a covered health care service, which health care reform law enacted in March 2010. References to is calculated as a percent of the allowed amount for the ACA at HPS typically involve reporting requirements, service. For example, your coinsurance is 20% (while the specifically, that obligate employers to report medica insurer pays the remaining 80%). coverage for employees and to provide documents for Contingent Beneficiary – This is who will receive a benefit in employee tax preparation. HPS partners with ACA service the event of the beneficiary’s (aka the primary beneficiary) providers to assist clients in meeting these requirements. death. A policy may have more than one contingent Actively-at-work – This term refers to being at work as beneficiary. opposed to being on vacation, leave, or away from work for Contingent Plans – Contingent plans make benefits available any other reason. Companywide or position-wide reporting to participants only when another specific benefit has been dates (like summer breaks or winter breaks for teachers) do elected. Examples of contingent plans include voluntary life not apply here. for dependents (contingent on the election of employee ADL (Activities of Daily Living) – This is a concept related to voluntary life) and a Health Saving Account (contingent on the eligibility for Long Term Care (LTC) benefits. There are six election of a High Deductible Health Plan). ADLs: bathing, dressing, toileting, transferring, eating, and Continuation of Coverage – Many plans offered by HPS continence. Most LTC plans require that the covered clients are continuable under COBRA or portability individual be unable to perform a certain number of these or conversion options. Standalone clients tasks to be eligible for benefits. and cooperatives will have “continuation of coverage” Beneficiary – This is who will receive a benefit in the event of documents that detail plan continuation availability. the insured’s death. A policy may have more than one Conversion – Conversion is a benefit continuation option that beneficiary. transforms group coverage into individual coverage, separate Benefit Duration – This is the maximum period of time in from the group policy. This typically comes with much higher which a claimant can receive benefits. premiums. Benefit Reduction – Some plans may include percentage reductions in benefit amounts when participants reach a certain age.
Covered Expenses – These are health care expenses covered under your health plan.
Deductible – This is the amount a participant must cover for Cafeteria/Section 125 Plan – This plan provides participants health care services before the insurer will share costs and an opportunity to pay for qualified benefits on a pretax basis. provide coinsurance. Premiums for most medical, dental, vision, FSA, HSA, Dental Reimbursement Types – Various types of dental accident, and cancer plans are deducted on a pretax basis, plans (except DHMO plans) will pay out-of-network benefits which reduces participants’ taxable income. differently. Certificate of Benefits (Certificate of Coverage) – The • MAC/MRC/NAP (Maximum Allowable Charge/Maximum certificate serves as the primary official plan document for Reimbursable Charge/Network Access participants of group benefits, as they are not enrolled in an Plan): Participants will receive the same payouts individual policy. (contracted fees) for services whether they go in or out of COBRA – COBRA allows participants who lose their health network; and they may be balance billed when going out of benefits the right to continue group health benefits for limited network. periods of time under certain circumstances including • UCR/R&C(Usual, Customary, and voluntary or involuntary job loss, reduction in the hours Reasonable/Reasonable & Customary): When going out worked, transition between jobs, death, divorce, and other life of network, the plan will pay an amount determined by the events. Qualified individuals will have to pay the full premium usual cost charged for the service by dentists in a certain (including any employer contribution applied when employed) geographical area. up to 102% of the cost to the plan. Coverage is typically available for 18 months but can be extended in certain situations. Copay – Also known as a copayment, this is the fixed amount you pay for health care services received at the time of service. A copay typically goes toward your deductible. 38
Coinsurance – After you have met your deductible, this is
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Glossary of Terms Eligibility Waiting Period – This period is the amount of time plan that combines lower monthly premiums in exchange for new hires must wait before they are eligible for benefits. Most higher deductibles and out-of-pocket limits. These plans are HPS clients will allow for new hires to be eligible the first of often coupled with an HSA. the month following (or coincident with) their date of hire. HMO/DHMO (Health Maintenance Organization/Dental Elimination Period – Also known as a waiting period, this is Health Maintenance Organization) – Medical plans labeled the number of calendar days that participants in a Disability as HMO plans have a specified network of providers, and plan must be disabled before they are eligible to receive benefits are generally not available outside of that network benefits. except in an emergency. DHMO plans follow this same model for dental coverage. Employer Contribution – The amount of premium or financial contribution an employer provides to participants for HPS (Higginbotham Public Sector) – HPS is the insurance insurance, spending accounts, or retirement. broker that represents your account.
EOB (Explanation of Benefits) – This statement from your HRA (Health Reimbursement Arrangement) – This is an insurance carrier explains which procedures and services employer-owned savings account to which the company were provided, how much they cost, what portion of the claim deposits pretax dollars for each of its covered employees. was paid by the plan, and what portion of the claim is your Employees can then use the funds in their HRA to reimburse responsibility. It also includes information on how you can themselves for incurred qualified health care expenses. appeal the insurer’s decision. These statements are also HSA (Health Savings Account) – This is an employee-owned posted on the carrier’s website for your review. savings account used to pay for eligible health care expenses EOI (Evidence of Insurability)/Statement of Health (SOH) – with pretax dollars. Funds in the account do not have to be Some plans require an application or a “proof of good health” used within a specified time period. An HSA must be coupled type of statement to obtain coverage. This is commonly with qualified HDHP. referred to as EOI (Evidence of Insurability). Such applications In-network – Doctors (e.g., a primary care physician or or statements must be submitted electronically or by mail to specialist), hospitals, and other providers that contract with the carrier for approval. your insurance company provide health care services at Evergreen Clause – This clause, written into a client’s discounted rates. These providers are on an outlined list of Cafeteria/Section 125 Plan, allows a client to roll over Flexible health care practitioners. Spending Account elections into the new plan year. Inpatient – A person who is treated as a registered patient in a FMLA (Family and Medical Leave Act) – This act ensures hospital or other health care facility. employees have job-protected and unpaid leave for qualified Medically Necessary – Services or supplies provided by a medical and family reasons. hospital, health care facility, or physician that meet the FSA (Flexible Spending Account) – An option that allows following criteria: (1) are appropriate for the symptoms and participants to set aside pretax dollars to pay for qualified diagnosis and/or treatment of the condition, illness, disease, expenses (i.e., certain medical care or dependent care or injury; (2) serve to provide diagnosis or direct care and/or expenses) during a specific period (usually a 12-month treatment of the condition, illness, disease, or injury; (3) are in period). Participants determine how much to contribute to accordance with standards of good medical practice; (4) are their FSA at the beginning of the plan year. Most funds must not primarily serving as convenience; and (5) are considered be used by the end of the year, depending upon the type of the most appropriate care available. FSA, as there is a limited carryover amount. Medicare – An insurance program administered by the Grace Period – As it pertains to FSAs, this is the period federal government to provide health coverage to individuals immediately following the end of the plan year during which age 65 or older, or who have certain disabilities or illnesses. participants can incur new claims to use their remaining FSA Member – You and those covered become members when funds. you enroll in a health plan. This includes eligible employees, Guaranteed Issue – Some plans may include Guaranteed their dependents, COBRA beneficiaries, and surviving Issue coverage to new enrollees without EOI. spouses.
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HDHP (High Deductible Health Plan – A qualified health
Glossary of Terms Open Enrollment – Open Enrollment refers to the annual event, treatment, or diagnosis that occurs prior to the period during which employees may enroll in available effective date of insurance coverage. benefits or make coverage changes without a Qualifying Life Pre-existing Condition Limitation – Some plans may limit Event. benefits due to pre-existing conditions for a set period of time. Out-of-network – Doctors, hospitals, and other providers that Premium – A reference to the cost (usually monthly) of are not contracted with your insurance company. If you insurance/benefits paid by the employer or employee. choose an out-of-network provider, you may be responsible for costs over the amount allowed by your insurance carrier. QLE (Qualifying Life Event) – These are events that allow changes to pretax benefits outside of Open Enrollment. Out-of-pocket Expense – Amount that you must pay toward Changes must typically be made within 30 or 31 days of the the cost of health care services. This includes deductibles, event. Examples of QLEs include marriage, birth, divorce, gain copayments, and coinsurance. or loss of benefits coverage, and change in employment Out-of-pocket Maximum – Also known as an out-of-pocket status affecting benefits. limit, this is the most you pay during a policy or benefit period Rate Guarantee – Plan pricing can be under a rate guarantee (usually a 12-month period) before your health insurance or for a certain amount of time, typically two to four years. The plan begins to pay 100% of the allowed amount for covered premium rates cannot be changed during this time. services. Renewal – When a plan’s rate guarantee expires, a rate PCP (Primary Care Physician) – A doctor who is selected to renewal will be received from the carrier’s underwriter. This coordinate treatment under your health plan. This generally establishes new rates beyond the expiration of the rate includes family practice physicians, general practitioners, guarantee. Clients can either accept the new rates, attempt internists, and pediatricians. to negotiate the renewal (usually assisted by HPS), or publish Plan Year – A 12-month period of benefits coverage under a an RFP (Request for Proposal) to shop for a new carrier. group health plan, which may or may not coincide with a Rollover – As it pertains to a Health Care FSA or Limited calendar year. Purpose Health Care FSA, a client can establish a limit of Plan Year Maximum – The maximum amount of benefit $680 (for 2026) of unused funds that can be rolled over to the available to a participant for each plan year. next plan year, provided the participant re-enrolls in the FSA plan. Portability – Portability is a continuation option available that allows participants to continue group coverage beyond their Run-out Period – Related to FSAs, this is a period employment. Premiums typically remain in line with active immediately following the end of the plan year in which participants, but coverage depends on the continuation of the participants can submit claims incurred within the plan year. group policy. If the group policy terminates, portability will no For new onboarding clients, this period can be managed by longer be available. the current or new administrator. The current administrator may charge a fee. If the new administrator manages the runPPO (Preferred Provider Organization) – Health plans out period, it will need a report of the FSA participants and labeled as PPO refer to the network structure and plan their remaining FSA balances. availability. In-network PPO plan providers have agreed to offer services at a contracted rate, which means members SSNRA (Social Security Normal Retirement Age) – This is generally pay less and get the highest level of benefits. Out-of-the normal retirement age for an employee under the federal network services and providers are also available, but you Social Security Act. may pay more for care and generally receive fewer benefits. Preventive Care – The care you receive to help prevent illness or disease. It also includes counseling to prevent health problems. Pre-existing Condition – A pre-existing condition is a medical
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Glossary of Terms SSDI (Social Security Disability Insurance) – Disability benefits are available through Social Security as long as a participant is “insured” (has worked long enough and paid into Social Security) and has been defined as disabled by the federal government. THEbenefitsHUB – This is the benefits enrollment system used by HPS.
This is the fee paid for covered services that is: (1) a similar amount to the fee charged by a health care provider to the majority of patients for the same procedure; (2) the customary fee paid to providers with similar training and expertise in a similar geographic area: and (3) reasonable in light of any unusual clinical circumstances.
Waiver of Premium (WOP) – This is a feature in some insurance plans that allows premiums to be suspended for Underwriting – This is the process of evaluating the risks of a participant for a period of disability. insuring an individual or group and establishing premium rates and coverage for the individual or group. Clients are subject to underwriting during RFPs and renewals, and their employees are subject to underwriting when submitting EOI statements for coverage. Usual, Customary and Reasonable (UCR) Allowance –
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Important Legal Notices Women’s Health and Cancer Rights Act of 1998
Marriage, Birth or Adoption If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 31 days after the marriage, birth, or placement for adoption.
In October 1998, Congress enacted the Women’s Health and Cancer benefits: All stages of reconstruction of theRights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully.
For More Information or Assistance To request special enrollment or obtain more information, contact: MRIC 2175 N Glenville Dr Richardson, TX 75082 833-870-2422
As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Your Prescription Drug Coverage and Medicare
• Prostheses and treatment of physical complications of the mastectomy, including lymphedema.
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with MRIC and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to enroll in a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan.
Special Enrollment Rights
If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or the dependents, as the case may be. However, you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future.
This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time. Loss of Other Coverage or Becoming Eligible for Medicaid or a state Children’s Health Insurance Program (CHIP)
Please note, however, that later notices might supersede this notice.
If you are declining coverage for yourself or your dependents because of other health insurance or group health plan coverage, you may be able to later 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 enroll within 31 days after your or your dependents’ other coverage ends (or after the employer that sponsors that coverage stops contributing toward the other coverage).
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that offers prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Your employer has determined that the prescription drug coverage offered by the employer medical plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage.
If you or your dependents lose eligibility under a Medicaid plan or CHIP, or if you or your dependents become eligible for a subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents in this plan. You must provide notification within 60 days after you or your dependent is terminated from, or determined to be eligible for, such assistance. 42
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Important Legal Notices The HSA plan is not considered Creditable Coverage.
For more information about your options under Medicare prescription drug coverage:
Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare prescription drug plan,as long as you later enroll within specific time periods.
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug coverage:
You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare. If you decide to wait to enroll in a Medicare prescription drug plan, you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as a general rule, if you delay your enrollment in Medicare Part D after first becoming eligible to enroll, you may have to pay a higher premium (a penalty).
• 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 877-486-2048.
You should compare your current coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting MRIC at the phone number or address listed at the end of this section.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you can call them at 800-7721213. TTY users should call 800-325-0778.
If you choose to enroll in a Medicare prescription drug plan and cancel your current MRIC prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. To regain coverage, you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage.
Remember: Keep this Creditable Coverage notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, 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 whether or not you are required to pay a higher premium (a penalty). MRIC 2175 N Glenville Dr Richardson, TX 75082 833-870-2422
If you cancel or lose your current coverage and do not have prescription drug coverage for 63 days or longer prior to enrolling in the Medicare prescription drug coverage, your monthly premium will be at least 1% per month greater for every month that you did not have coverage for as long as you have Medicare prescription drug coverage. For example, if nineteen months lapse without coverage, your premium will always be at least 19% higher than it would have been without the lapse in coverage. For more information about this notice or your current prescription drug coverage: Contact the Human Resources Department at 833-8702422. NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage and if this coverage changes. You may also request a copy. 43
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Important Legal Notices Notice of HIPAA Privacy Practices
Treatment is the provision, coordination or management of health care and related services. It also includes but is not limited to consultations and referrals between one or more of your providers.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
For example, the Plan may disclose to a treating physician the name of your treating radiologist so that the physician may ask for your X-rays from the treating radiologist.
Effective Date of Notice: September 23, 2013
MRIC’s Plan is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:
Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims processing, subrogation, reviews for medical necessity and appropriateness of care, utilization review and preauthorizations).
1. the Plan’s uses and disclosures of Protected Health Information (PHI);
For example, the Plan may tell a treating doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.
2. your privacy rights with respect to your PHI;
3. the Plan’s duties with respect to your PHI; 4. your right to file a complaint with the Plan and to the Secretary of the U.S. Department of Health and Human Services; and
Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. However, no genetic information can be used or disclosed for underwriting purposes.
5. the person or office to contact for further information about the Plan’s privacy practices. The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic). Section 1 – Notice of PHI Uses and Disclosures
Required PHI Uses and Disclosures
For example, the Plan may use information to project future benefit costs or audit the accuracy of its claims processing functions.
Upon your request, the Plan is required to give you access to your PHI in order to inspect and copy it. Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Plan’s compliance with the privacy regulations.
Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release. Unless you object, the Plan may provide relevant portions of your protected health information to a family member, friend or other person you indicate is involved in your health care or in helping you receive payment for your health care. Also, if you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, the Plan will disclose protected health information (as the Plan determines) in your best interest. After the emergency, the Plan will give you the opportunity to object to future disclosures to family and friends.
Uses and disclosures to carry out treatment, payment and health care operations. The Plan and its business associates will use PHI without your authorization to carry out treatment, payment and health care operations. The Plan and its business associates (and any health insurers providing benefits to Plan participants) may also disclose the following to the Plan’s Board of Trustees: (1) PHI for purposes related to Plan administration (payment and health care operations); (2) summary health information for purposes of health or stop loss insurance underwriting or for purposes of modifying the Plan; and (3) enrollment information (whether an individual is eligible for benefits under the Plan). The Trustees have amended the Plan to protect your PHI as required by federal law.
Uses and disclosures for which your consent, authorization or opportunity to object is not required.
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Important Legal Notices The Plan is allowed to use and disclose your PHI without your authorization under the following circumstances:
When required for law enforcement purposes, including for the purpose of identifying or locating a suspect, fugitive, material witness or missing person. Also, when disclosing information about an individual who is or is suspected to be a victim of a crime but only if the individual agrees to the disclosure or the Plan is unable to obtain the individual’s agreement because of emergency circumstances. Furthermore, the law enforcement official must represent that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individual’s agreement and disclosure is in the best interest of the individual as determined by the exercise of the Plan’s best judgment.
1. For treatment, payment and health care operations. 2. Enrollment information can be provided to the Trustees. 3. Summary health information can be provided to the Trustees for the purposes designated above. 4. When required by law. 5. When permitted for purposes of public health activities, including when necessary to report product defects and to permit product recalls. PHI may also be disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if required by law.
10. When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent.
6. When required by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In which case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made. Disclosure may generally be made to the minor’s parents or other representatives although there may be circumstances under federal or state law when the parents or other representatives may not be given access to the minor’s PHI.
11. When consistent with applicable law and standards of ethical conduct if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat. 12. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.
7. The Plan may disclose your PHI to a public health oversight agency for oversight activities required by law. This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud).
Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization. Uses and disclosures that require your written authorization.
8. The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request.
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Important Legal Notices Other uses or disclosures of your protected health information not described above will only be made with your written authorization. For example, in general and subject to specific conditions, the Plan will not use or disclose your psychiatric notes; the Plan will not use or disclose your protected health information for marketing; and the Plan will not sell your protected health information, unless you provide a written authorization to do so. You may revoke written authorizations at any time, so long as the revocation is in writing. Once the Plan receives your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.
Designated Record Set Includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for the Plan; or other information used in whole or in part by or for the Plan to make decisions about individuals. Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set.
The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained off site. A single 30-day extension is allowed if the Plan is unable to comply with the deadline.
Section 2 – Rights of Individuals
You or your personal representative will be required to submit a written request to request access to the PHI in your designated record set. Such requests should be made to the Plan’s Privacy Official.
Right to Request Restrictions on Uses and Disclosures of PHI You may request the Plan to restrict the uses and disclosures of your PHI. However, the Plan is not required to agree to your request (except that the Plan must comply with your request to restrict a disclosure of your confidential information for payment or health care operations if you paid for the services to which the information relates in full, out of pocket).
If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a description of how you may appeal the Plan’s decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services.
You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official.
The Plan may charge a reasonable, cost-based fee for copying records at your request. Right to Amend PHI
Right to Request Confidential Communications
You have the right to request the Plan to amend your PHI or a record about you in your designated record set for as long as the PHI is maintained in the designated record set.
The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations if necessary to prevent a disclosure that could endanger you.
The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI.
You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official. Right to Inspect and Copy PHI You have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains the PHI. If the information you request is in an electronic designated record set, you may request that these records be transmitted electronically to yourself or a designated individual.
Such requests should be made to the Plan’s Privacy Official. You or your personal representative will be required to submit a written request to request amendment of the PHI in your designated record set.
Protected Health Information (PHI) Includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form. 46
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Important Legal Notices Right to Receive an Accounting of PHI Disclosures
This Notice is effective September 23, 2013, and the Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice is changed, a revised version of this Notice will be provided to all participants for whom the Plan still maintains PHI. The revised Notice will be distributed in the same manner as the initial Notice was provided or in any other permissible manner.
At your request, the Plan will also provide you an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting will not include PHI disclosures made: (1) to carry out treatment, payment or health care operations; (2) to individuals about their own PHI; (3) pursuant to your authorization; (4) prior to April 14, 2003; and (5) where otherwise permissible under the law and the Plan’s privacy practices. In addition, the Plan need not account for certain incidental disclosures.
If the revised version of this Notice is posted, you will also receive a copy of the Notice or information about any material change and how to receive a copy of the Notice in the Plan’s next annual mailing. Otherwise, the revised version of this Notice will be distributed within 60 days of the effective date of any material change to the Plan’s policies regarding the uses or disclosures of PHI, the individual’s privacy rights, the duties of the Plan or other privacy practices stated in this Notice.
If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided.
If you request more than one accounting within a 12month period, the Plan will charge a reasonable, costbased fee for each subsequent accounting. Such requests should be made to the Plan’s Privacy Official.
Minimum Necessary Standard When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. When required by law, the Plan will restrict disclosures to the limited data set, or otherwise as necessary, to the minimum necessary information to accomplish the intended purpose.
Right to Receive a Paper Copy of This Notice Upon Request You have the right to obtain a paper copy of this Notice. Such requests should be made to the Plan’s Privacy Official. A Note About Personal Representatives
You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms:
However, the minimum necessary standard will not apply in the following situations: 1. disclosures to or requests by a health care provider for treatment;
1. a power of attorney for health care purposes;
2. uses or disclosures made to the individual;
2. a court order of appointment of the person as the conservator or guardian of the individual; or
3. disclosures made to the Secretary of the U.S. Department of Health and Human Services;
3. an individual who is the parent of an unemancipated minor child may generally act as the child’s personal representative (subject to state law).
4. uses or disclosures that are required by law; and
5. uses or disclosures that are required for the Plan’s compliance with legal regulations.
The Plan retains discretion to deny access to your PHI by a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.
De-Identified Information This notice does not apply to information that has been deidentified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual.
Section 3 – The Plan’s Duties The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of the Plan’s legal duties and privacy practices. 47
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Important Legal Notices Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
Summary Health Information The Plan may disclose “summary health information” to the Trustees for obtaining insurance premium bids or modifying, amending or terminating the Plan. “Summary health information” summarizes the claims history, claims expenses or type of claims experienced by participants and excludes identifying information in accordance with HIPAA.
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs, but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
Notification of Breach The Plan is required by law to maintain the privacy of participants’ PHI and to provide individuals with notice of its legal duties and privacy practices. In the event of a breach of unsecured PHI, the Plan will notify affected individuals of the breach.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
Section 4 – Your Right to File a Complaint With the Plan or the HHS Secretary If you believe that your privacy rights have been violated, you may complain to the Plan. Such complaints should be made to the Plan’s Privacy Official.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877- KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
You may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint. Section 5 – Whom to Contact at the Plan for More Information
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you have any questions regarding this notice or the subjects addressed in it, you may contact the Plan’s Privacy Official. Such questions should be directed to the Plan’s Privacy Official at:
MRIC 2175 N Glenville Dr Richardson, TX 75082 833-870-2422
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of March 17, 2025. Contact your State for more information on eligibility.
Conclusion
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations.
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Important Legal Notices Continuation of Coverage Rights Under COBRA
Texas – Medicaid Website: https://www.hhs.texas.gov/services/financial/healthinsurance-premium-payment-hipp-program Phone: 1-800-440-0493
Under the Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), if you are covered under the MRIC group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the MRIC plan after you have left employment with the company. If you wish to elect COBRA coverage, contact your Human Resources Department for the applicable deadlines to elect coverage and pay the initial premium.
To see if any other States have added a premium assistance program since March 17, 2025, or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
Plan Contact Information: MRIC 2175 N Glenville Dr Richardson, TX 75082 833-870-2422
Your Rights and Protections Against Surprise Medical Bills When you get emergency care or get treated by an outof- network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-ofnetwork providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of- pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care— like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
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Important Legal Notices You are protected from balance billing for:
Your health plan generally must:
• Emergency services – If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s innetwork cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-ofnetwork providers. • Base what you owe the provider or facility (costsharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
• Certain services at an in-network hospital or ambulatory surgical center – When you get services from an in- network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you believe you have been wrongly billed, you may contact your insurance provider. Visit www.cms.gov/nosurprises for more information about your rights under federal law.
If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network. When balance billing is not allowed, you also have the following protections: • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay outof-network providers and facilities directly.
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Notes
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This brochure highlights the main features of the MRIC Region 2 employee benefits program. It does not include all plan rules, details, limitations, and exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are the final authority. MRIC Region 2 reserves the right to change or discontinue its employee benefits plans at anytime.