Bell County2019-2020 Employee Benefits Booklet

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ContentsHealth and Dental Insurance Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Health and Dental Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Scott & White Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Naturally Slim Overview – For Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

MDLIVE® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Ameritas Dental Insurance and Vision Reimbursement Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Colonial Life Voluntary Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

The Medicare D Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

HIPAA Model Privacy Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

CHIPRA Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Special Enrollment Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Women’s Health and Cancer Rights Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Newborns Act Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

The information contained in this booklet is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Should there be differences between the information in the booklet and the contract, the contract will govern.

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Baylor Scott & White Preferred Network (Smaller Network) Cost County Employee Employee Cost ($30 Copay, $1,250/$2,500 Ded, Co-Insurance 80/20%) per Month Contribution Cost per Month per Pay Period {RX - Unlimited Maximum}

EMPLOYEE ONLY 546.50 546.50 0.00 0.00

EMPLOYEE/SPOUSE 1,349.47 546.50 802.97 401.49

EMPLOYEE/CHILDREN 957.04 546.50 410.54 205.27

FAMILY 1,640.76 546.50 1,094.26 547.13

0% increase. Baylor Scott & White Preferred providers belong to the Baylor Scott & White Quality Alliance Accountable Care Organization and are contracted with Scott & White Health Plan to provide care for you. No change to Plan Design.

Scott & White HMO (Broader Network) Cost County Employee Employee Cost ($30 Copay, $1,250/$2,500 Ded, Co-Insurance 80/20%) per Month Contribution Cost per Month per Pay Period {RX - Unlimited Maximum}

EMPLOYEE ONLY 598.43 546.50 51.93 25.97 EMPLOYEE/SPOUSE 1,477.71 546.50 931.21 465.61

EMPLOYEE/CHILDREN 1,047.99 546.50 501.49 250.75

FAMILY 1,796.68 546.50 1,250.18 625.09

0% increase. Network is a Broader Network within Scott & White - Allows members to go to Doctors and Hospitals in a

larger network within the Scott & White Network . Example to include Seaton in Harker Heights.

No change to Plan Design.

Ameritas Dental Coverage - Employer Sponsored Base Cost County Employee Employee Cost (Dental with Preventive Plus / Maximum Allowable Charges per Month Contribution Cost per Month per Pay Period and a Vision Reimbursement Benefit)

EMPLOYEE ONLY 19.56 19.56 0.00 0.00

FAMILY 69.48 19.56 49.92 24.96 0% Increase. No change to Plan Design.

Ameritas Dental Coverage - Voluntary Buy-Up Cost County Employee Employee Cost (Dental with Preventive Plus / 90th Percentile per Month Contribution Cost per Month per Pay Period and a Vision Reimbursement Benefit)

EMPLOYEE ONLY 28.24 19.56 8.68 4.34

FAMILY 92.40 19.56 72.84 36.42 0% Increase. No change to Plan Design.

Visit www.https://bellcounty.swhp.org for details on the health insurance.Visit www.ameritas.com for details on the dental insurance.

Dated 06/25/2019

BELL COUNTYINSURANCE RATES FOR CONTRACT YEAR 2019-2020

Costs (with Tax Credit) - Current Benefits Package(contribution matching rate for Employee Only, Baylor Scott & White Preferred Network (Smaller Network)

(contribution matching rate for Employee Only, Ameritas Dental, Base Plan)

COVERAGE FOR ALL INSURANCE (Health, Dental, & Life)will be effective the First of the Month following 30 days of employment

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Scott & White Health Plan Benefits Benefits are the same for the Baylor Scott & White Preferred Network and Scott & White HMO

Annual Deductible Applies to Out of Pocket Max

$1,250 Individual $2,500 Family

Annual Out of Pocket Maximum $3,750 Individual $7,500 Family

Max Lifetime Benefit per member None

Primary Care Office Visit $30 copay; deductible waived

Specialty Care Office Visit $30 copay; deductible waived

Virtual Visit $10 copay; deductible waived

Preventive Services No Charge

Standard Lab & X-ray No Charge

Diagnostic/Radiology Procedures 20% after deductible Up to the out of pocket maximum

Eye Exam (1 refraction annually) $30 copay; deductible waived

Outpatient Surgery 20% after deductible Up to the out of pocket maximum

Inpatient Hospital 20% after deductible Up to the out of pocket maximum

Emergency Room Services $250 copay, plus 20% of charges Up to the out of pocket maximum

Urgent Care Services $75 Copay

Ambulance 20% after deductible Up to the out of pocket maximum

Prescription Drug Plan Retail Quantity

(All Network Pharmacies) (up to a 34-day supply or 100 units, whichever is less)

No Annual Maximum No Deductible

Preferred Generic: $10 copay Preferred Brand: $40 copay

Non-Preferred: Lesser of $100 or 50% Specialty Drug 10%/20%/30%

Prescription Drug Plan Maintenance Quantity

(SWHP Pharmacies Only) (up to a 90-day supply or 360 units, whichever is less)

No Annual Maximum No Deductible

Preferred Generic: $20 copay Preferred Brand: $80 copay

Non-Preferred: Lesser of $200 or 50%

Ameritas Dental Plan Benefits Employer Sponsored Base Plan Voluntary Buy-Up

Deductible $10 per Visit for Preventive; $50/Policy Year/Individual for Basic and Major; Ortho Exempt

$10 per Visit for Preventive; $50/Policy Year/Individual for Basic and Major; Ortho Exempt

Reimbursement Level (Out-of-Network) Maximum Allowable Charges 90th Percentile

Preventive Services $10 per visit charge Cleanings (2 per policy year), x-rays, exams, flouride, sealants

$10 per visit charge Cleanings (2 per policy year), x-rays, exams, flouride, sealants

Basic Services 20% after deductible Basic restorative, simple extractions, root canals

20% after deductible Basic restorative, simple extractions, root canals

Major Services 50% after deductible Onlays, crowns, bridges, dentures, and implants

50% after deductible Onlays, crowns, bridges, dentures, and implants

Orthodontic Services 50%, No deductible Dependent under age 19 / Lifetime Max. $1,000

50%, No deductible Dependent under age 19 / Lifetime Max. $1,000

Vision Reimbursement Reimbursement up to $150 for exams, frames, lenses, and contact lenses. Not limited to any provider.

Reimbursement up to $150 for exams, frames, lenses, and contact lenses. Not limited to any provider.

RX SavingsMembers and dependents (even their pets) can save on prescription medications through any Walmart or Sam’s

Club pharmacy nationwide.

Members and dependents (even their pets) can save on prescription medications through any Walmart or Sam’s Club

pharmacy nationwide.

Policy Year Maximum (Nov. 1 - Oct. 31) $1,000 per Individual excludes Preventive $1,000 per Individual excludes Preventive

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Scott and White Health PlanBel l County BSW Preferred Member Guide

Letter from Our CEO...........................................................................................1

Changing Healthcare for the Better..........................................................2

Member Portal .......................................................................................................4

Wellness Program ................................................................................................5

Maternity and Preventive Care .....................................................................7

Don’t Overspend .................................................................................................8

Pharmacy Benefits ............................................................................................10

ID Cards.....................................................................................................................11

Explanation of Benefits (EOB).....................................................................12

Disease/Complex Case Management....................................................13

Network Map..........................................................................................................15

Table of Contents

SWAdmin_257_2017

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan. These companies will be referred to collectively in this document as Scott and White Health Plan.

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Dear Health Benefits Member:

Welcome to Scott and White Health Plan, and thank you for allowing us to provide your health insurance coverage. This booklet is intended to help you make the most of the tools and resources available through SWHP.

Through the course of the year, you may want to review your claims, start a wellness program, find a new provider, or order a new ID card. We want to make sure you know where to go to get started. Use our online tools for quick and easy self-service or contact one of our customer advocates for personal assistance through our toll-free telephone number or through the secure, online messaging tool.

SWHP is committed to providing the highest caliber of care for Texans – we are here to help you be as healthy as you can. SWHP scored above state and national averages in categories ranging from breast cancer screenings to colorectal cancer screenings to controlling high blood pressure for members 18 to 85 years old. Our consistently high scores on clinical measures reflect our dedication and focus on quality.

We hope you will get engaged with your own health, take advantage of the tools we offer, and benefit from our attention to positive customer interactions and favorable clinical outcomes.

Thank you again for choosing Scott and White Health Plan to serve your healthcare coverage needs.

Jeff Ingrum

President and Chief Executive OfficerScott and White Health Plan

SCOTT and WHITE HEALTH PLAN1206 West Campus Drive • Temple, Texas 76502

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Changing Healthcare for the BetterThe integration of care delivery and a health plan creates the opportunity for a more seamless experience for you, making your life easier while saving you money.

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• Assists members in managing chronic disease

• Prevents the onset of disease through preventive health screenings

• Proactive outreach vs. reactive treatment

• Convenient access to high- quality, compassionate doctors

• Holistic approach to member care – we know your health history

• Unnecessary trips to the emergency room and admissions to the hospital are avoided

• Fewer claims due to fewer health crises

BETTER HEALTH BETTER CARE BETTER VALUE

Baylor Scott & White Preferred creates a collaborative environment where doctors and health plan administrators work alongside each other.

When you select a primary care doctor, they act as the quarterback for your care, treating you and directing care teams to ensure a comprehensive, coordinated, high-quality member experience is achieved.

Care is coordinated by a centralized team of nurse care managers, health coordinators and licensed social workers who work with you to help you get the most out of treatment plans set by your doctor. Follow-up visits are scheduled, medications are reconciled, preventive screenings are arranged when due, and you are connected with community resources, as appropriate.

Data is shared securely among primary and specialty care doctors, hospitals, labs and post-acute care facilities as well as the insurance plan. This can help you avoid unnecessary tests or procedures and billing.

Doctors can share in savings that come from improving quality and efficiency, leading to lower out-of-pocket medical costs and trends that are less than the national average.

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Changing Healthcare for the Better

Member is newly diagnosed with diabetes Type 2

• Member is presented with 30 minutes of instruction on managing their diabetes along with a number of printed discharge papers outlining instructions

• Member is asked to follow up with an endocrinologist

• Member is referred to an endocrinologist and RN Care Manager

• Follow-up appointment is scheduled with the endocrinologist before member leaves the office

• RN Care Manager follows up with member to ensure discharge instructions are understood, medications reconciled, and prescriptions filled

Member needs an annual physical exam

• Member is responsible for scheduling annual physical exam

• Member is directed to HealthAccess, a centralized resource for finding a doctor and navigating the healthcare system

• A HealthAccess representative helps member find a doctor near his/her work

• An appointment is made for the following week

Member sees a specialist as recommended by his/her primary care doctor

• Specialist is not fully aware of member’s health history and orders a battery of tests that have already been done

• Specialist pulls up the member’s health chart in the electronic health record (EHR)

• Specialist reviews member’s health history including test results

• Specialist runs appropriate tests and records them in the EHR

• Repeat tests are avoided and an appropriate treatment plan is devised

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Get the Most from Your Service Experience

Through the Member Portal

View and print ID cards instantly

View benefits and coverage

See your claims andExplanations of Benefits (EOBs)

View your deductible andout-of-pocket accumulator

At bellcounty.swhp.org, sign up and log in to the Member Portal to get answers to most of your benefits questions.

Take a wellness assessment

Set your preferences

Review Evidence of Coverageand other plan documents

e-mail customer servicethrough secure messaging

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LOG IN

SIGN UP NOW

Choose from a broad range of in-network providers by using the provider search tool. 1. Select Member Type: Commercial.2. Select a plan: choose the “BSW Preferred” plan that applies to you (HMO, PPO, EPO).

Not sure which plan to choose? Find it on your member ID card.3. Search for providers by name and/or specialty.4. Determine providers’ distance from your ZIP code.

Find a network provider

All of the same information from the portal is available on your phone. Plus, you can access MyChart to track

your appointments and results with Baylor Scott & White providers. To log in, use the same user name and

password you set up for the Member Portal.

Or on the MYBSWHealth App

It’s usually a good idea to set up an appointment with your provider to get acquainted, at your convenience. Referrals are not required to see network specialists, even in our HMO network.

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Wellness AssessmentThe Wellness Assessment is a simple, digital health survey that helps you take steps toward a more vibrant and healthier life. The Wellness Assessment asks questions about your life and delivers customized action steps from our Lifestyle Management Program. Modules are self-paced, available online, and convenient for promoting physical and mental health — all things to help you feel your best.

Taking care of yourself isn’t a fad, it’s a good habit. And it’s a habit anyone can pick up. Let our Wellness programs improve the areas of your life that could use a boost.

SWHP offers a variety of programming designed to meet your health and wellness needs regardless of where you may be on the continuum of care. Providing a comprehensive suite of effective resources and tools, we provide a tailored experience built on the demands of our members. We strive to continuously provide the right care, in the right place, at the right time. It is our mission to promote a healthy lifestyle and empower our members to become an active participant on their healthcare team.

SWHP Wellness Program

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Assessment for Members Assessment for Non-Members

Log in and select Wellness Assessment

Sign in and select Challenges

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SWHP Online Wellness Programs Scott and White Health Plan supports healthy choices by providing individual personalized plans that fit your life and needs. These plans can include any of the following lifestyle management programs:

Balance – Manage Your Weight. Your mind, body, and food habits are all key to managing your weight. Balance addresses all three to help you reach your goals and maximize your energy.

Nourish – Eat Healthier. Helps you improve your eating habits and your overall relationship with food, one bite at a time.

Relax – Deal with Stress. Puts your sources and symptoms of tension under a microscope, then unveils strategies to help keep you calm under pressure.

Breathe – Quit Smoking. Gives you the skills to help conquer your cravings and say “goodbye” to cigarettes for good.

Care for Depression. Provides individualized help in the setting and at the time of your choice.

Dream – Sleep Better. Short on energy and focus during the day? Dream is packed with research-based strategies for conquering sleepless nights.

Care for Your Health. Be the quarterback of your healthcare team, not a spectator. Care for Your Health reveals tactics and secrets to help you handle any chronic condition.

Care for Pain. Your pain is unique and so is the way you respond to it. Care for Pain helps you focus more on the things that matter most to you.

To participate in any of the Lifestyle Management programs, visit swhp.org/health and log in.

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Maternity Topics and MOMS ProgramGet important information and resources for new moms and dads from our MOMS program that supports families following the birth of a newborn with personal phone calls by a licensed professional.

A MOMS program professional can be reached toll-free at 888-316-7947.

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Find recommended preventive services here:

http://www.cdc.gov/prevention/

Create a schedule of vaccines.

1. Make a schedule of recommended immunizations for your child from birth through 6 years here:

http://www2a.cdc.gov/nip/ kidstuff/newscheduler_le/

2. Then, review the schedule with your child’s doctor.

Take an online vaccination quiz.Take an online vaccination quiz to see which vaccines you or your children may need by going here:

English:http://www2a.cdc.gov/nip/

adultimmsched/

Spanish:http://www2a.cdc.gov/nip/adultimmsched/quiz-sp.asp

Get Preventive

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Visit your Primary Care Physician when you’re sick or have a minor injury...1

Your doctor knows your health history and underlying conditions. For routine illnesses and less significant injuries, many doctors’ offices are open on weekends and some evenings. This can be a good alternative to more costly urgent care or emergency care centers.

If your doctor’s office is closed, consider anUrgent Care center.2

Urgent care centers typically have extended and weekend hours. Although costs are higher than primary care, urgent care copays are lower than those for emergency care.

Don’t Overspendto Get the Care You NeedHow do you decide when a health-related issue is an emergency? Understanding your healthcare options can save your life — and your money.

... or use the Nurse Advice Line Nurses are available to our members 24 hours a day, 365 days a year. Our nurses provide information about taking care of yourself at home or they can help you decide if an appointment, an urgent care visit, or an emergency room visit is best for your symptoms. To locate your appropriate Nurse Advice Line phone number, please look on the back of your member card or log in to the Member Portal.

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If you need to speak to us, contact us in the way that works for you. In addition to the Member Portal, customer support is available by phone at 800-321-7947.

Scott and White Health Plan pays out-of-network emergency services accord ing to Usual and Customary rates (industry standard), and members can be balance-billed for expenses beyond what insurance will pay. Your coverage documents contain additional information about emergency treatment and definitions of the terms, including a definition of emergency care. The coverage documents also contain information related to state-mandated consumer protections for facility-based provider charges.

To save on out-of-pocket costs, visit in-network emergency care facilities when possible.

Out-of-Network Emergency Care Costs More

Emergency Rooms are best for treating severe and life-threatening conditions. 3

The wider range of services offered through emergency rooms, and the hospitals they are connected to, makes emergency care a more expensive option, but sometimes the best option for you.

It’s important to understand your options, and to use your best judgment when deciding which option is right for you.

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Pharmacy ServicesSWHP members may access more than 68,000 pharmacies nationwide, including most national chains and a large selection of local pharmacies.

To find your nearest pharmacy, click here:

PHARMACY SEARCH

We also offer 90-day prescription refills for select medications at Baylor Scott & White Health pharmacies.

Get the convenience of home delivery with mail order service. Call our mail-order pharmacy and we will walk you through the transfer process.

Call toll-free at 855-388-3090 Monday through Friday, from 7 a.m. to 7 p.m., and on Saturday, from 9 a.m. to 1 p.m.

If you need detailed pharmacy claim information, pharmacy deductible information, explanation of benefits, or drug information and pricing, visit bellcounty.swhp.org or call 1-800-321-7947.

To view a formulary, please click here:

FORMULARIES

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back to top The ID card above is a sample. The exact location of certain elements may vary on your card.

You can access an electronic card at any time through the MyBSWHealth app or the Member Portal. You can also request a replacement ID card through the Portal.

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Claims mailing address and electronic claims submission ID

Information Found on Your Member ID Card

Your insurance carrier

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Your member number and

group number

Please contact Scott & White Health Plan Health Services Departmenttoll free at 866-384-3488 for pre-authorization requests (including BehavioralHealth and Second Opinions). If you require inpatient admission following anemergency, please notify SWHP within 48 hours of emergency services.

Plan Information/provider list: swhp.org ..Nurse Advice Line: 877-505-7947Customer Service: 800-321-7947 ............OptumRx Help Desk: 855-205-9182

Notice To ProvidersVerify benefits and eligibility at portal.swhp.org/providerportal or 800-321-7947

Please send claims and related correspondence to:Scott & White Health Plan | Availity Payer ID 88030Attn: Claims PO Box 21800, Eagan, MN 55121-0800254-298-3000 or 800-321-7947

NOTICE: Possession of this card or obtaining precertification does notguarantee coverage or payment for the service or procedure reviewed.Your pharmacy

plan number and copay information

Your coverage information

Information for providers

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3

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1

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3RX BIN:

Network:Primary:Specialist:

123456789JOHN DOE

Group No.:

RX PCN:

Issue Date:

Member No. Member Name123456789001234567890112345678902

JOHN DOEJAMIE DOEJACKSON DOE

TDI

RX Group: Urgent:

Contract No.:

Emergency:RX Copay:

2

Your plan type:HMO, PPO or EPO

211

BSW Preferred HMO

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SWHP makes available through the Member Portal an electronic Monthly Insurance Statement, also known as an Explanation of Benefits, to help you manage your claims expenses at a detailed level. The statement provides line-item detail on charges for that month, including what was billed and covered by SWHP. The amount you owe is included in this statement.

Remaining balances for deductibles and out-of-pocket expenses are also reported. Information for the current month and year-to-date is included. Statements are not provided for prescription claims or claims where the member does not owe anything.

Your EOBs will be delivered electronically through the portal unless you specifically request to receive paper EOBs in the mail. To request paper EOBs, log in to the Member Portal and select “Update Preferences.”

Get Full Claims Detailwith your monthly insurance statement

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Even if your EOB isn’t yet finalized for a particular medical claim, you can still view your claim details in Scott and White Health Plan’s Member Portal.

Don’t Wait for Your EOB View your claim on the Member Portal

Then click on any amount under “Plan Pays” to view the Claim Snapshot or Service Details. The Claim Snapshot provides key claim information, and Service Details itemizes the claim.

Click the SAVE icon to create a file that can be printed or saved.

EOBs are added to the portal monthly. Click on the Claim Number (in Claim No. column) to see your EOB.

Simply log in to the Member Portal through

bellcounty.swhp.org and click on “Claims”

from the menu on the left side.

Claim Snapshot

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SWHP Complex Case Management Our Complex Case Management program helps you if you have chronic conditions or complex care needs. A nurse case manager will work with you, your family, and the physician to create a plan to meet your ongoing complex care needs. Case managers advocate for you and assist you with setting goals and making a personal plan to improve your health. They can also assist with arrangements for necessary services and make referrals to, and incorporate, Disease Management programs as applicable. Case managers answer questions and educate you so you have a better understanding of your condition and plan of care. The purpose of the program is to help you get the best possible results and the greatest value from your health plan. Participation is voluntary, and there is no additional cost to you for this program.

For more information, please contact the BSWQA HealthAccess line at 1-844-BSW-QLTY (1-844-279-7589).

SWHP Disease Management Disease Management programs are designed to improve the health of persons with chronic conditions and reduce associated costs from avoidable complications. These goals are accomplished by identifying and treating chronic conditions more quickly and more effectively, slowing the progression of those diseases. Disease Management is a system of coordinated healthcare interventions tailored to your conditions where self-care efforts can be implemented. Disease Management empowers you, working with your healthcare providers, to manage the disease and prevent complications.

For more information, please contact the BSWQA HealthAccess line at 1-844-BSW-QLTY (1-844-279-7589).

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Service Areas

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BSW Preferred Service Area Map

AustinBastrop

Bell

Blanco

Bosque

Brazos

Brown

Burleson

Burnet

Caldwell

Comanche

Cooke

Coryell

Dallas

Denton

Ellis

Falls

Fannin

Fayette

Gillespie

Grayson

Grimes

Hamilton

Hays

Henderson

Hill

Hood

Hunt

Kaufman

Lampasas

Lee

Limestone

Llano

McCulloch

McLennan

Madison

Mason Milam

Mills

Navarro

Parker

Robertson

Rockwall

San Saba

Tarrant

Travis

Waller

Williamson

Wise

Johnson

Collin

Somervell

Washington

HMO: Only certain ZIP codes in Johnson, Milam and Travis counties are included.PPO/ EPO: Only certain ZIP codes in Johnson and Travis counties are included.

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Thank you for choosing Scott and White Health Plan to serve your healthcare coverage needs.

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan. These companies will be referred to collectively in this document as Scott and White Health Plan.

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ore i

nform

ation

abou

t you

r cov

erag

e, or

to ge

t a co

py of

the c

omple

te ter

ms of

cove

rage

, visi

t bell

coun

ty.sw

hp.or

g, or

call 1

-800

-321

-79

47. F

or ge

nera

l defi

nition

s of c

ommo

n ter

ms, s

uch a

s allo

wed a

moun

t, bala

nce b

illing

, coin

sura

nce,

copa

ymen

t, ded

uctib

le, pr

ovide

r, or

othe

r und

erlin

ed te

rms

see t

he G

lossa

ry. Y

ou ca

n view

the G

lossa

ry at

cciio

.cms.g

ov or

call 1

-800

-321

-794

7 to r

eque

st a c

opy.

Impo

rtant

Que

stio

ns

Answ

ers

Why

Thi

s Mat

ters

:

Wha

t is t

he o

vera

ll de

duct

ible?

Netw

ork p

rovid

er: $

1,250

ind

ividu

al / $

2,500

fami

ly. D

oesn

’t ap

ply to

prev

entiv

e car

e.

Gene

rally

, you

mus

t pay

all o

f the c

osts

from

prov

iders

up to

the d

educ

tible

amou

nt be

fore t

his

plan b

egins

to pa

y. If y

ou ha

ve ot

her f

amily

mem

bers

on th

e plan

, eac

h fam

ily m

embe

r mus

t mee

t the

ir own

indiv

idual

dedu

ctible

until

the to

tal am

ount

of de

ducti

ble ex

pens

es pa

id by

all fa

mily

memb

ers m

eets

the ov

erall

fami

ly de

ducti

ble.

Are t

here

serv

ices

cove

red

befo

re yo

u m

eet

your

ded

uctib

le?

Yes.

Pre

venti

ve ca

re an

d prim

ary

care

servi

ces a

re co

vere

d befo

re

you m

eet y

our d

educ

tible.

This

plan c

over

s som

e item

s and

servi

ces e

ven i

f you

have

not y

et me

t the d

educ

tible

amou

nt.

But a

copa

ymen

t or c

oinsu

ranc

e may

apply

. For

exam

ple, th

is pla

n cov

ers p

reve

ntive

servi

ces

witho

ut co

st sh

aring

and b

efore

you m

eet y

our d

educ

tible.

See

a lis

t of c

over

ed pr

even

tive

servi

ces a

t hea

lthca

re.go

v/cov

erag

e/pre

venti

ve-ca

re-b

enefi

ts/.

Are t

here

oth

er

dedu

ctib

les fo

r spe

cific

serv

ices?

No

. Yo

u do n

ot ha

ve to

mee

t ded

uctib

les fo

r spe

cific

servi

ces.

Wha

t is t

he o

ut-o

f-poc

ket

limit

for t

his p

lan?

Netw

ork p

rovid

er: $

3,750

per

indivi

dual

/ $7,5

00 pe

r fam

ily.

The o

ut-of-

pock

et lim

it is t

he m

ost y

ou co

uld pa

y in a

year

for c

over

ed se

rvice

s. If

you h

ave o

ther

family

mem

bers

in thi

s plan

, the o

vera

ll fam

ily ou

t-of-p

ocke

t limi

t mus

t be m

et.

Wha

t is n

ot in

clude

d in

th

e out

-of-p

ocke

t lim

it?

Copa

ymen

ts on

certa

in se

rvice

s, pr

emium

s, ba

lance

-billi

ng

char

ges,

and h

ealth

care

this

plan

does

not c

over

.

Even

thou

gh yo

u pay

thes

e exp

ense

s, the

y don

’t cou

nt tow

ard t

he ou

t-of-p

ocke

t limi

t.

Will

you

pay l

ess i

f you

us

e a n

etwo

rk p

rovid

er?

Yes.

See

bellc

ounty

.swhp

.org o

r ca

ll 1-8

00-3

21-7

947 f

or a

list o

f ne

twor

k pro

vider

s.

This

plan u

ses a

prov

ider n

etwor

k. Y

ou w

ill pa

y les

s if y

ou us

e a pr

ovide

r in th

e plan

’s ne

twor

k. Yo

u will

pay t

he m

ost if

you u

se an

out-o

f-netw

ork p

rovid

er, a

nd yo

u migh

t rec

eive a

bill f

rom

a pr

ovide

r for

the d

iffere

nce b

etwee

n the

prov

ider’s

char

ge an

d wha

t you

r plan

pays

(bala

nce

billin

g). B

e awa

re yo

ur ne

twor

k pro

vider

migh

t use

an ou

t-of-n

etwor

k pro

vider

for s

ome s

ervic

es

(such

as la

b wor

k). C

heck

with

your

prov

ider b

efore

you g

et se

rvice

s.

Do yo

u ne

ed a

refe

rral t

o se

e a sp

ecial

ist?

No.

You c

an se

e the

spec

ialist

you c

hoos

e with

out a

refer

ral.

* Fo

r mor

e in

form

atio

n ab

out l

imita

tions

and

exc

eptio

ns, s

ee th

e pl

an o

r pol

icy

docu

men

t at b

ellc

ount

y.sw

hp.o

rg

23

2 of

8

All c

opay

men

t and

coin

sura

nce c

osts

show

n in t

his ch

art a

re af

ter yo

ur d

educ

tible

has b

een m

et, if

a ded

uctib

le ap

plies

.

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Im

porta

nt In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u vis

it a h

ealth

ca

re p

rovid

er’s

offic

e or

clin

ic

Prim

ary c

are v

isit to

trea

t an

injur

y or il

lness

$3

0 cop

ay pe

r visi

t No

t cov

ered

No

ne

Spec

ialist

visit

$3

0 cop

ay pe

r visi

t No

t cov

ered

No

ne

Prev

entiv

e car

e/scre

ening

/ im

muniz

ation

No

char

ge

Not c

over

ed

You m

ay ha

ve to

pay f

or se

rvice

s tha

t ar

en’t p

reve

ntive

. Ask

your

prov

ider if

the

servi

ces n

eede

d are

prev

entiv

e. Th

en

chec

k wha

t you

r plan

will

pay f

or.

If yo

u ha

ve a

test

Di

agno

stic t

est (

x-ray

, bloo

d wo

rk)

No ch

arge

No

t cov

ered

So

me se

rvice

s tha

t are

not p

reau

thoriz

ed

will b

e den

ied. R

efer t

o swh

p.org

or

Custo

mer S

ervic

e at 1

-800

-321

-794

7.

Imag

ing (C

T/PE

T sc

ans,

MRIs)

20

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

If yo

u ne

ed d

rugs

to

treat

your

illne

ss o

r co

nditi

on

More

infor

matio

n abo

ut pr

escr

iptio

n dr

ug

cove

rage

is av

ailab

le at

bellc

ounty

.swhp

.org/p

harm

acy-i

nform

ation

.

Prefe

rred g

ener

ic dr

ugs

$10 c

opay

per 3

0-da

y sup

ply /

retai

l $2

0 cop

ay pe

r 90-

day s

upply

/ ma

inten

ance

. De

ducti

ble do

es no

t app

ly

Not c

over

ed

Copa

ys ar

e per

30-d

ay su

pply.

Two

co

pays

apply

for a

90-d

ay su

pply

if a

maint

enan

ce dr

ug is

obtai

ned t

hrou

gh a

Baylo

r Sco

tt & W

hite p

harm

acy O

R wh

en

using

the m

ail or

der p

resc

riptio

n ser

vice.

Sp

ecific

prev

entat

ive m

edica

tions

will

be

cove

red w

ith no

cost

to the

mem

ber.

Prefe

rred b

rand

drug

s

$40 c

opay

per 3

0-da

y sup

ply /

retai

l $8

0 cop

ay pe

r 90-

day s

upply

/ ma

inten

ance

De

ducti

ble do

es no

t app

ly

Not c

over

ed

Non-

prefe

rred g

ener

ic dr

ugs

and n

on-p

refer

red b

rand

drug

s

Less

er of

$100

or 50

% co

pay

per 3

0-da

y sup

ply / r

etail

Less

er of

$200

or 50

% co

pay

per 9

0-da

y sup

ply /

maint

enan

ce

Dedu

ctible

does

not a

pply

Not c

over

ed

Spec

ialty

drug

s Le

vel 1

– 10

% of

char

ges

Leve

l 2 –

20%

of ch

arge

s Le

vel 3

– 30

% of

char

ges

Dedu

ctible

does

not a

pply

Not c

over

ed

Some

drug

s may

requ

ire pr

ior

autho

rizati

on. 3

0-da

y sup

ply on

ly.

24

3 of

8

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Im

porta

nt In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u ha

ve o

utpa

tient

su

rger

y

Facil

ity fe

e (e.g

., amb

ulator

y su

rger

y cen

ter)

20%

after

dedu

ctible

No

t cov

ered

So

me se

rvice

s tha

t are

not p

reau

thoriz

ed

will b

e den

ied. R

efer t

o swh

p.org

or

Custo

mer S

ervic

e at 1

-800

-321

-794

7. Ph

ysici

an/su

rgeo

n fee

s 20

% af

ter de

ducti

ble

Not c

over

ed

If yo

u ne

ed im

med

iate

med

ical a

ttent

ion

Emer

genc

y roo

m ca

re

$250

copa

y; plu

s 20%

of

char

ges

$250

copa

y; plu

s 20%

of

char

ges

Copa

y waiv

ed if

episo

de re

sults

in

hosp

italiz

ation

for t

he sa

me co

nditio

n wi

thin 2

4 hou

rs.

Em

erge

ncy m

edica

l tra

nspo

rtatio

n 20

% af

ter de

ducti

ble

20%

after

dedu

ctible

No

ne

Urge

nt ca

re

$75 c

opay

per v

isit

$75 c

opay

per v

isit

If yo

u ha

ve a

hosp

ital

stay

Fa

cility

fee (

e.g., h

ospit

al ro

om)

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

Phys

ician

/surg

eon f

ees

20%

after

dedu

ctible

No

t cov

ered

If yo

u ne

ed m

enta

l he

alth,

beh

avio

ral

healt

h, o

r sub

stan

ce

abus

e ser

vices

Outpa

tient

servi

ces

$30 c

opay

per v

isit

Not c

over

ed

Some

servi

ces t

hat a

re no

t pre

autho

rized

wi

ll be d

enied

. Refe

r to s

whp.o

rg or

Cu

stome

r Ser

vice a

t 1-8

00-3

21-7

947.

Inpati

ent s

ervic

es

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

If yo

u ar

e pre

gnan

t

Offic

e visi

ts $3

0 cop

ay pe

r visi

t No

t cov

ered

Co

st sh

aring

does

not a

pply

for pr

even

tive

care

. No c

harg

e for

pren

atal v

isits;

po

stnata

l visi

ts ar

e cov

ered

at th

e sp

ecial

ist co

pay.

Child

birth/

deliv

ery p

rofes

siona

l se

rvice

s 20

% af

ter de

ducti

ble

Not c

over

ed

Some

servi

ces t

hat a

re no

t pre

autho

rized

wi

ll be d

enied

. Refe

r to s

whp.o

rg or

Cu

stome

r Ser

vice a

t 1-8

00-3

21-7

947.

Child

birth/

deliv

ery f

acilit

y se

rvice

s 20

% af

ter de

ducti

ble

Not c

over

ed

If yo

u ne

ed h

elp

reco

verin

g or

hav

e ot

her s

pecia

l hea

lth

need

s

Home

healt

h car

e $3

0 cop

ay pe

r visi

t No

t cov

ered

No

ne

Reha

bilita

tion s

ervic

es

$30 c

opay

per v

isit

Not c

over

ed

Bene

fit ma

ximum

of 20

visit

s per

calen

dar

year

, bas

ed up

on m

edica

l nec

essit

y; ad

dition

al 10

visit

s in h

ome o

nly.

25

4 of

8

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Im

porta

nt In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

Habil

itatio

n ser

vices

$3

0 cop

ay pe

r visi

t No

t cov

ered

Bene

fit ma

ximum

of 20

visit

s per

calen

dar

year

, bas

ed up

on m

edica

l nec

essit

y; ad

dition

al 10

visit

s in h

ome o

nly.

Skille

d nur

sing c

are

20%

after

dedu

ctible

No

t cov

ered

Pr

e-ce

rtifica

tion r

equir

ed.

Dura

ble m

edica

l equ

ipmen

t 50

% af

ter de

ducti

ble

Not c

over

ed

None

Ho

spice

servi

ces

No ch

arge

No

t cov

ered

No

ne

If yo

ur ch

ild n

eeds

de

ntal

or ey

e car

e

Child

ren’s

eye e

xam

$30 c

opay

per v

isit

Not c

over

ed

One e

xam

limit p

er ye

ar.

Child

ren’s

glas

ses

Not c

over

ed

Not c

over

ed

None

Ch

ildre

n’s de

ntal c

heck

-up

Not c

over

ed

Not c

over

ed

None

Ex

clude

d Se

rvice

s & O

ther

Cov

ered

Ser

vices

: Se

rvice

s You

r Plan

Gen

erall

y Doe

s NOT

Cov

er (C

heck

your

pol

icy o

r plan

doc

umen

t for

mor

e inf

orm

atio

n an

d a l

ist o

f any

oth

er ex

clude

d se

rvice

s.)

• Ac

upun

cture

•

Baria

tric su

rger

y •

Cosm

etic s

urge

ry

• De

ntal c

are (

Child

and A

dult)

• Inf

ertili

ty tre

atmen

t •

Long

-term

care

•

Non-

emer

genc

y car

e whe

n tra

velin

g outs

ide U

.S.

• Pr

ivate-

duty

nursi

ng

• Ro

utine

foot

care

•

Weig

ht los

s pro

gram

s

Othe

r Cov

ered

Ser

vices

(Lim

itatio

ns m

ay ap

ply t

o th

ese s

ervic

es. T

his i

sn’t

a com

plet

e list

. Plea

se se

e you

r plan

doc

umen

t.)

• Ch

iropr

actic

care

(limi

ted to

35 vi

sits p

er C

alend

ar ye

ar)

• He

aring

aids

(limi

ted to

one p

er ea

r eve

ry thr

ee ye

ars f

or co

vere

d mem

bers

18 ye

ars o

f age

or yo

unge

r) •

Routi

ne ey

e car

e (Ad

ult) (

limite

d to a

nnua

l eye

exam

cond

ucted

by a

licen

sed o

phtha

lmolo

gist o

r opto

metris

t) Yo

ur R

ight

s to

Cont

inue

Cov

erag

e: T

here

are a

genc

ies th

at ca

n help

if yo

u wan

t to co

ntinu

e you

r cov

erag

e afte

r it en

ds. T

he co

ntact

infor

matio

n for

thos

e ag

encie

s is:

Scott

& W

hite C

are P

lans,

visit s

whp.o

rg, o

r call

1-80

0-32

1-79

47; D

epar

tmen

t of L

abor

’s Em

ploye

e Ben

efits

Secu

rity A

dmini

strati

on at

1-86

6-44

4-EB

SA

(327

2) or

dol.g

ov/eb

sa/he

althr

eform

; Tex

as D

epar

tmen

t of In

sura

nce,

visit t

di.tex

as.go

v or c

all 1-

800-

578-

4677

. Othe

r cov

erag

e opti

ons m

ay be

avail

able

to yo

u too

, inc

luding

buyin

g ind

ividu

al ins

uran

ce co

vera

ge th

roug

h the

Hea

lth In

sura

nce M

arke

tplac

e. Fo

r mor

e info

rmati

on ab

out th

e Mar

ketpl

ace,

visit H

ealth

Care

.gov o

r call

1-80

0-31

8-25

96.

Your

Grie

vanc

e and

App

eals

Righ

ts: T

here

are a

genc

ies th

at ca

n help

if yo

u hav

e a co

mplai

nt ag

ainst

your

plan

for a

denia

l of a

claim

. This

comp

laint

is ca

lled a

gr

ievan

ce or

appe

al. F

or m

ore i

nform

ation

abou

t you

r righ

ts, lo

ok at

the e

xplan

ation

of be

nefits

you w

ill re

ceive

for t

hat m

edica

l clai

m. Y

our p

lan do

cume

nts al

so

prov

ide co

mplet

e info

rmati

on to

subm

it a cl

aim, a

ppea

l, or a

griev

ance

for a

ny re

ason

to yo

ur pl

an. F

or m

ore i

nform

ation

abou

t you

r righ

ts, th

is no

tice,

or as

sistan

ce,

conta

ct: S

cott &

Whit

e Car

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27

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28

7 of 8

29

8 of 8

30

SWHP Online Wellness Programs Scott and White Health Plan supports healthy choices by providing individual personalized plans that fit your life and needs. These plans can include any of the following lifestyle management programs:

Balance – Manage Your Weight. Your mind, body, and food habits are all key to managing your weight. Balance addresses all three to help you reach your goals and maximize your energy.

Nourish – Eat Healthier. Helps you improve your eating habits and your overall relationship with food, one bite at a time.

Relax – Deal with Stress. Puts your sources and symptoms of tension under a microscope, then unveils strategies to help keep you calm under pressure.

Breathe – Quit Smoking. Gives you the skills to help conquer your cravings and say “goodbye” to cigarettes for good.

Care for Depression. Provides individualized help in the setting and at the time of your choice.

Dream – Sleep Better. Short on energy and focus during the day? Dream is packed with research-based strategies for conquering sleepless nights.

Care for Your Health. Be the quarterback of your healthcare team, not a spectator. Care for Your Health reveals tactics and secrets to help you handle any chronic condition.

Care for Pain. Your pain is unique and so is the way you respond to it. Care for Pain helps you focus more on the things that matter most to you.

To participate in any of the Lifestyle Management programs, visit swhp.org/health and log in, you will be redirected to the Wellness platform where you can click on the Coaching link.

1

Scott and White Health PlanBell County HMO Member Guide

Letter from Our CEO............................................................................1

Member Portal ........................................................................................2

Your ID Card ..............................................................................................3

Pharmacy Services..............................................................................4

Don’t Overspend ...................................................................................5

Wellness Program .................................................................................7

Maternity and Preventive Care......................................................9

Explanation of Benefits (EOB)......................................................10

Disease/Complex Case Management.....................................12

Additional Member Information ..................................................13

Network Map..........................................................................................14

Table of Contents

SWHP_12-2018

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan. These companies will be referred to collectively in this document as Scott and White Health Plan.

31

Dear Health Benefits Member:

Welcome to Scott and White Health Plan, and thank you for allowing us to provide your health insurance coverage. This booklet is intended to help you make the most of the tools and resources available through SWHP.

Through the course of the year, you may want to review your claims, start a wellness program, find a new provider, or order a new ID card. We want to make sure you know where to go to get started. Use our online tools for quick and easy self-service or contact one of our customer advocates for personal assistance through our toll-free telephone number or through the secure, online messaging tool.

SWHP is committed to providing the highest caliber of care for Texans – we are here to help you be as healthy as you can. SWHP scored above state and national averages in categories ranging from breast cancer screenings to colorectal cancer screenings to controlling high blood pressure for members 18 to 85 years old. Our consistently high scores on clinical measures reflect our dedication and focus on quality.

We hope you will get engaged with your own health, take advantage of the tools we offer, and benefit from our attention to positive customer interactions and favorable clinical outcomes.

Thank you again for choosing Scott and White Health Plan to serve your healthcare coverage needs.

Jeff Ingrum

President and Chief Executive OfficerScott and White Health Plan

SCOTT and WHITE HEALTH PLAN1206 West Campus Drive • Temple, Texas 76502

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32

2

Get the Most from Your Service Experience

Through the Member Portal...

View and print ID cards instantly

View benefits and coverage

See your claims andExplanations of Benefits (EOBs)

View your deductible andout-of-pocket accumulator

At bellcounty.swhp.org , sign up and log in to the Member Portal to get answers to most of your benefits questions.

Take a wellness assessment

Set your preferences

Review Evidence of Coverageand other plan documents

E-mail customer servicethrough secure messaging

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LOG IN

SIGN UP NOW

Choose from a broad range of in-network providers by using the provider search tool at https://portal.swhp.org/#/search. It’s usually a good idea to set up an appointment with your provider to get acquainted, at your convenience. With our provider search tool, you can:

Search by name and/or specialty

Determine providers’ distance from your ZIP code

Find a network provider.

All of the same information from the portal is available on your phone. Plus, you can access MyChart to track

your appointments and results with Baylor Scott & White providers. To log in, use the same user name and

password you set up for the Member Portal.

...or on the

MYBSWHealth App

Referrals are not required to see network specialists, even in our HMO network.

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33

9

RX PCN:Group No.:Office Visit:Specialist:

123456789JOHN DOE

RX BIN:

RX Group:

Issue Date:Network:

Member No. Member Name123456789001234567890112345678902

JOHN DOEJAMIE DOEJACKSON DOE

RX Copay: ER/Urgent:

HMO

TDI

Contract No.:

/93078

BSW Preferred HMO

Claims mailing address and electronic claims submission ID

Information Found on Your Member ID Card

Your benefits administrator/insurance carrier

1 2

6

3Your contract

number, pharmacy plan number, and pharmacy copay

information

Your plan type: HMO, HMO-POS, PPO, HRA, or HSA

2

Your member number

Your group number and coverage

information

Information for providers

6

3

4

1

5

77

The ID card above is a sample. The exact location of certain elements may vary on your card.

You can request a replacement ID card through the Member Portal oraccess an electronic card at any time through the MyBSWHealth app.

5

4

3

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Please contact Scott & White Health Plan Health Services Departmenttoll free at 866-384-3488 for pre-authorization requests (including BehavioralHealth and Second Opinions). If you require inpatient admission following anemergency, please notify SWHP within 48 hours of emergency services.

Plan Information/provider list: swhp.org ..Nurse Advice Line: 877-505-7947Customer Service: 800-321-7947 ............OptumRx Help Desk: 855-205-9182

Notice To ProvidersVerify benefits and eligibility at portal.swhp.org/providerportal or 800-321-7947

Please send claims and related correspondence to:Scott & White Health Plan | Availity Payer ID 88030Attn: Claims PO Box 21800, Eagan, MN 55121-0800254-298-3000 or 800-321-7947

NOTICE: Possession of this card or obtaining precertification does notguarantee coverage or payment for the service or procedure reviewed.

3

34

4

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Pharmacy ServicesSWHP members may access more than 68,000 pharmacies nationwide, including most national chains and a large selection of local pharmacies.

To find your nearest pharmacy, click here:

PHARMACY SEARCH

We also offer 90-day prescription refills for select medications at Baylor Scott & White Health pharmacies.

Get the convenience of home delivery with mail order service. Call our mail-order pharmacy and we will walk you through the transfer process.

Call toll-free at 855-388-3090 Monday through Friday, from 7 a.m. to 7 p.m., and on Saturday, from 9 a.m. to 1 p.m.

If you need detailed pharmacy claim information, pharmacy deductible information, explanation of benefits, or drug information and pricing, visit bellcounty.swhp.org or call 1-800-321-7947.

To view a formulary, click here:

FORMULARIES

35

Visit your Primary Care Physicianwhen you’re sick or have a minor injury...1

Your doctor knows your health history and underlying conditions. For routine illnesses and less significant injuries, many doctors’ offices are open on weekends and some evenings. This can be a good alternative to more costly urgent care or emergency care centers.

If your doctor’s office is closed, consider an

Urgent Care center.2Urgent care centers typically have extended and weekend hours. Although costs are higher than primary care, urgent care copays are lower than those for emergency care.

Don’t Overspendto Get the Care You NeedHow do you decide when a health-related issue is an emergency? Understanding your healthcare options can save your life – and your money.

... or use the Nurse Advice Line Nurses are available to our members 24 hours a day, 365 days a year. Our nurses provide information about taking care of yourself at home or they can help you decide if an appointment, an urgent care visit, or an emergency room visit is best for your symptoms. To locate your appropriate Nurse Advice Line phone number, please look on the back of your member card or log in to the Member Portal.

5

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36

If you need to speak to us, contact us in the way that works for you. In addition to the Member Portal, customer support is available by phone at 800-321-7947.

Scott and White Health Plan pays out-of-network emergency services accord ing to Usual and Customary rates (industry standard), and members can be balance-billed for expenses beyond what insurance will pay. Your coverage documents contain additional information about emergency treatment and definitions of the terms, including a definition of emergency care. The coverage documents also contain information related to state-mandated consumer protections for facility-based provider charges.

To save on out-of-pocket costs, visit in-network emergency care facilities when possible.

Out-of-Network Emergency Care Costs More

Emergency Roomsare best for treating severe and life-threatening conditions. 3

The wider range of services offered through emergency rooms, and the hospitals they are connected to, makes emergency care a more expensive option, but sometimes the best option for you.

It’s important to understand your options, and to use your best judgment when deciding which option is right for you.

6

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37

SWHP Wellness AssessmentThe Wellness Assessment is a simple, digital health survey that helps you take steps toward a more vibrant and healthier life. The Wellness Assessment asks questions about your life and delivers customized action steps from our Lifestyle Management Program. Modules are self-paced, available online, and convenient for promoting physical and mental health — all things to help you feel your best.

Taking care of yourself isn’t a fad, it’s a good habit. And it’s a habit anyone can pick up. Let our Wellness programs improve the areas of your life that could use a boost.

SWHP offers a variety of programming designed to meet your health and wellness needs regardless of where you may be on the continuum of care. Providing a comprehensive suite of effective resources and tools, we offer a tailored experience built on the demands of our members. We strive to continuously provide the right care, in the right place, at the right time. It is our mission to promote a healthy lifestyle and empower our members to become an active participant of their healthcare team.

SWHP Wellness Program

Assessment for Members Assessment for Non-Members

7

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38

8

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SWHP Online Wellness Programs Scott and White Health Plan supports healthy choices by providing individual personalized plans that fit your life and needs. These plans can include any of the following lifestyle management programs:

Balance – Manage Your Weight. Your mind, body, and food habits are all key to managing your weight. Balance addresses all three to help you reach your goals and maximize your energy.

Nourish – Eat Healthier. Helps you improve your eating habits and your overall relationship with food, one bite at a time.

Relax – Deal with Stress. Puts your sources and symptoms of tension under a microscope, then unveils strategies to help keep you calm under pressure.

Breathe – Quit Smoking. Gives you the skills to help conquer your cravings and say “goodbye” to cigarettes for good.

Care for Depression. Provides individualized help in the setting and at the time of your choice.

Dream – Sleep Better. Short on energy and focus during the day? Dream is packed with research-based strategies for conquering sleepless nights.

Care for Your Health. Be the quarterback of your healthcare team, not a spectator. Care for Your Health reveals tactics and secrets to help you handle any chronic condition.

Care for Pain. Your pain is unique and so is the way you respond to it. Care for Pain helps you focus more on the things that matter most to you.

To participate in any of the Lifestyle Management programs, visit swhp.org/health and log in, you will be redirected to the Wellness platform where you can click on the Coaching link.

39

Maternity Topics and MOMS ProgramGet important information and resources for new moms and dads from our MOMS program. You’ll receive personal phone calls from a licensed professional support families following the birth of a newborn.

A MOMS program professional can be reached toll-free at 888-316-7947.

Find recommended preventive services here:http://www.cdc.gov/prevention/

Create a schedule of vaccines.

1. Make a schedule ofrecommended immunizations for your child from birththrough 6 years here:

http://www2a.cdc.gov/nip/kidstuff/newscheduler_le/

2. Then, review the schedulewith your child’s doctor.

Take an online vaccination quiz.Take an online vaccination quiz to see which vaccines you or your children may need by going here:

English:http://www2a.cdc.gov/nip/

adultimmsched/

Spanish:http://www2a.cdc.gov/nip/adultimmsched/quiz-sp.asp

Get Preventive 9

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40

10

Get Full Claims Detailwith your monthly insurance statement

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SWHP makes available through the Member Portal an electronic Monthly Insurance Statement, also known as an Explanation of Benefits, to help you manage your claims expenses at a detailed level. The statement provides line-item detail on charges for that month, including what was billed and covered by SWHP. The amount you owe is included in this statement.

Remaining balances for deductibles and out-of-pocket expenses are also reported. Information for the current month and year-to-date is included. Statements are not provided for prescription claims or claims where the member does not owe anything.

Your EOBs will be available on the Member Portal unless you specifically request to receive paper EOBs in the mail. To request paper EOBs, log in to the Member Portal and select “Update Preferences.”

41

11

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Even if your EOB isn’t yet finalized for a particular medical claim, you can still view your claim details in Scott and White Health Plan’s Member Portal.

Don’t Wait for Your EOB View your claim on the Member Portal

Then click on any amount under “Plan Pays” to view the Claim Snapshot or Service Details. The Claim Snapshot provides key claim information, and Service Details itemizes the claim.

Click the SAVE icon to create a file that can be printed or saved.

EOBs are added to the portal monthly. Click on the Claim Number (in Claim No. column) to see your EOB.

Simply log in to the Member Portal through

bellcounty.swhp.org and click on “Claims”

from the menu on the left side.

Claim Snapshot

42

12

SWHP Complex Case Management Our Complex Case Management program helps you if you have chronic conditions or complex care needs. A nurse case manager will work with you, your family, and the physician to create a plan to meet your ongoing complex care needs. Case managers advocate for you and assist you with setting goals and making a personal plan to improve your health. They can also assist with arrangements for necessary services and make referrals to, and incorporate, Disease Management programs as applicable. Case managers answer questions and educate you so you have a better understanding of your condition and plan of care. The purpose of the program is to help you get the best possible results and the greatest value from your health plan. Participation is voluntary, and there is no additional cost to you for this program.

For more information, please log in to the Member Portal, select Wellness Programs and request a screening to see if Complex Case Management is the right program for your needs.

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SWHP Disease Management Disease Management programs are designed to improve the health of persons with chronic conditions and reduce associated costs from avoidable complications. These goals are accomplished by identifying and treating chronic conditions more quickly and more effectively, slowing the progression of those diseases. Disease Management is a system of coordinated healthcare interventions tailored to your conditions where self-care efforts can be implemented. Disease Management empowers you, working with your healthcare providers, to manage the disease and prevent complications.

SWHP members can access the program by calling 888-360-1555 or through the following link: Member Information Center.

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43

13

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Tools & ResourcesOur most frequently requested documents and forms are available within our Tools and Resources section. Select the Menu from the Individuals and Families section, then select Tools and Resources to locate information about:

• Member Rights and Responsibilities

• Notice of Privacy Practices and Authorization to Release PHI Form

• Prior Authorization List for Medical Procedures

• Complex Case Management Program with Multiple Referral Options

• Disease Management Program

• Utilization Management (UM) Program- How to Access UM Staff- TDD/TTY Services for Members- Language Assistance for Members- Utilization Management Affirmative Statement

• Quality Improvement Program and Progress in Achieving Goals

• Medical and Pharmacy Claim Forms

• Pharmaceutical Management Procedures and Updates

• Wellness Assessment and Programs

• Glossary of Key Terms

• Technology Assessment Program

• Language Assistance

• Member Frequently Asked Questions (FAQ):- Submit a Claim- Obtain Information About Participating Providers- Obtain Primary, Specialty, and Behavioral Healthcare- Obtain Hospital Services- Get Care After Normal Office Hours- Get Care Outside the SWHP Service Area- When to Call 911- File Complaints and/or Appeals

Printed copies of documents and language assistance are available by calling

800-321-7947.

44

14

Service Areas

Anderson

Andrews

Angelina

Aransas

Archer

Armstrong

Atascosa

Austin

Bailey

Bandera

Baylor

Bee

Bell

Bexar

Blanco

Borden

Bosque

Bowie

Brazoria

Brazos

Brewster

Briscoe

Brooks

Brown

Burleson

Burnet

Calhoun

Callahan

Cameron

Camp

Carson

Cass

Castro

Chambers

Cherokee

Childress

Clay

Cochran

Coke

Coleman

Collingsworth

Colorado

Comal

Comanche

Concho

Cooke

Coryell

Cottle

Crane

Crockett

Crosby

Culberson

Dallam

DallasDawson

Deaf Smith

Delta

De Witt

Dickens

Dimmit

Donley

Duval

Eastland

Ector

Edwards

Ellis

El Paso

Erath

Falls

Fannin

Fayette

Fisher

FloydFoard

Fort Bend

Franklin

Freestone

Frio

Gaines

Galveston Galveston

Garza

Gillespie

Glasscock

Goliad

Gonzales

Gray

Grayson

Gregg

Grimes

Guadalupe

Hale

Hall

Hamilton

Hansford

Hardeman

Hardin

Harris

Harrison

Hartley

Haskell

Hemphill

Henderson

Hidalgo

Hill

Hockley

Hood

Hopkins

Houston

Howard

Hudspeth

Hunt

Hutchinson

Irion

Jack

Jackson

Jasper

Jeff Davis

Jefferson

Jim Hogg

JimWells

Jones

Karnes

Kaufman

Kendall

Kenedy

Kent

Kerr

Kimble

King

Kinney

Kleberg

KnoxLamar

Lamb

Lampasas

La Salle

Lavaca

Lee

Leon

Liberty

Limestone

Lipscomb

Live Oak

Llano

Loving

Lubbock

Lynn

McCulloch

McLennan

McMullen

Madison

Marion

Martin

Mason

MatagordaMaverick

Medina

Menard

Midland

Milam

Mills

Mitchell

Montague

Montgomery

Moore

Morris

Motley

Nacogdoches

Navarro

Newton

Nolan

Nueces

Ochiltree

Oldham

Orange

Palo Pinto

Panola

Parker

Parmer

Pecos Polk

Potter

Presidio

Rains

Randall

Reagan

Real

Red River

Reeves

Refugio

Roberts

Robertson

Rockwall

Runnels

Rusk

Sabine

SanAugustine

SanJacinto

San Patricio

San Saba

Schleicher

ScurryShackleford

Shelby

Sherman

Smith

Starr

Stephens

Sterling

Stonewall

Sutton

Swisher

Tarrant

Taylor

Terrell

Terry Throckmorton Titus

TomGreen

Travis

Trinity

Tyler

Upshur

Upton

Uvalde

Val Verde

VanZandt

Victoria

Walker

Waller

Ward

Webb

Wharton

Wheeler

WichitaWilbarger

Willacy

Williamson

Wilson

Winkler

Wise

Wood

Yoakum Young

Zapata

Zavala

Johnson

Collin

Somervell

Bastrop

Washington

Hays

Caldwell

Denton

HMO/POS, PPO and EPO

HMO/POS only

back to top

Austin

Bell

Blanco

Bosque

Brazos

Burleson

Burnet

Coke

Coleman

Concho Coryell

Crockett

Dallas

Denton

Ellis

Erath

Falls

Fayette

Freestone

Grimes

Hamilton

Hays

Hill

Hood

Irion

Kimble

Lampasas

Lee

Leon

Limestone

Llano

McCulloch

McLennan

Madison

MasonMenard

Milam

Mills

Reagan

Robertson

Rockwall

Runnels

San Saba

Schleicher

Sterling

Sutton

Tarrant

TomGreen

Travis

Walker

Waller

Washington

Williamson

Bastrop

Caldwell

Johnson

Somervell

Collin

Bexar

Comal

El Paso

HMO/POS and PPO only

45

Thank you for choosing Scott and White Health Plan for your healthcare coverage needs.

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan. These companies will be referred to collectively in this document as Scott and White Health Plan.

46

Sum

mar

y of B

enef

its an

d Co

vera

ge: W

hat th

is Pl

an C

over

s & W

hat Y

ou P

ay F

or C

over

ed S

ervic

es

Cove

rage

Per

iod:

11/01

/2019

– 10

/31/20

20

Scot

t & W

hite

Car

e Plan

s: B

ell C

ount

y SW

CP H

MO

Co

vera

ge fo

r: Ind

ividu

al + F

amily

| Plan

Typ

e: C

C

1 of 8

The S

umm

ary o

f Ben

efits

and

Cove

rage

(SBC

) doc

umen

t will

help

you

choo

se a

healt

h pl

an. T

he S

BC sh

ows y

ou h

ow yo

u an

d th

e plan

wou

ld

shar

e the

cost

for c

over

ed h

ealth

care

serv

ices.

NOTE

: Inf

orm

atio

n ab

out t

he co

st o

f thi

s plan

(call

ed th

e pre

miu

m) w

ill be

pro

vided

sepa

rate

ly.

This

is on

ly a s

umm

ary.

For m

ore i

nform

ation

abou

t you

r cov

erag

e, or

to ge

t a co

py of

the c

omple

te ter

ms of

cove

rage

, visi

t bell

coun

ty.sw

hp.or

g, or

call 1

-800

-321

-79

47. F

or ge

nera

l defi

nition

s of c

ommo

n ter

ms, s

uch a

s allo

wed a

moun

t, bala

nce b

illing

, coin

sura

nce,

copa

ymen

t, ded

uctib

le, pr

ovide

r, or

othe

r und

erlin

ed te

rms

see t

he G

lossa

ry. Y

ou ca

n view

the G

lossa

ry at

cciio

.cms.g

ov or

call 1

-800

-321

-794

7 to r

eque

st a c

opy.

Impo

rtant

Que

stio

ns

Answ

ers

Why

Thi

s Mat

ters

:

Wha

t is t

he o

vera

ll de

duct

ible?

Netw

ork p

rovid

er: $

1,250

ind

ividu

al / $

2,500

fami

ly. D

oesn

’t ap

ply to

prev

entiv

e car

e.

Gene

rally

, you

mus

t pay

all o

f the c

osts

from

prov

iders

up to

the d

educ

tible

amou

nt be

fore t

his

plan b

egins

to pa

y. If y

ou ha

ve ot

her f

amily

mem

bers

on th

e plan

, eac

h fam

ily m

embe

r mus

t mee

t the

ir own

indiv

idual

dedu

ctible

until

the to

tal am

ount

of de

ducti

ble ex

pens

es pa

id by

all fa

mily

memb

ers m

eets

the ov

erall

fami

ly de

ducti

ble.

Are t

here

serv

ices

cove

red

befo

re yo

u m

eet

your

ded

uctib

le?

Yes.

Pre

venti

ve ca

re an

d prim

ary

care

servi

ces a

re co

vere

d befo

re

you m

eet y

our d

educ

tible.

This

plan c

over

s som

e item

s and

servi

ces e

ven i

f you

have

not y

et me

t the d

educ

tible

amou

nt.

But a

copa

ymen

t or c

oinsu

ranc

e may

apply

. For

exam

ple, th

is pla

n cov

ers p

reve

ntive

servi

ces

witho

ut co

st sh

aring

and b

efore

you m

eet y

our d

educ

tible.

See

a lis

t of c

over

ed pr

even

tive

servi

ces a

t hea

lthca

re.go

v/cov

erag

e/pre

venti

ve-ca

re-b

enefi

ts/.

Are t

here

oth

er

dedu

ctib

les fo

r spe

cific

serv

ices?

No

. Yo

u do n

ot ha

ve to

mee

t ded

uctib

les fo

r spe

cific

servi

ces.

Wha

t is t

he o

ut-o

f-poc

ket

limit

for t

his p

lan?

Netw

ork p

rovid

er: $

3,750

per

indivi

dual

/ $7,5

00 pe

r fam

ily.

The o

ut-of-

pock

et lim

it is t

he m

ost y

ou co

uld pa

y in a

year

for c

over

ed se

rvice

s. If

you h

ave o

ther

family

mem

bers

in thi

s plan

, the o

vera

ll fam

ily ou

t-of-p

ocke

t limi

t mus

t be m

et.

Wha

t is n

ot in

clude

d in

th

e out

-of-p

ocke

t lim

it?

Copa

ymen

ts on

certa

in se

rvice

s, pr

emium

s, ba

lance

-billi

ng

char

ges,

and h

ealth

care

this

plan

does

not c

over

.

Even

thou

gh yo

u pay

thes

e exp

ense

s, the

y don

’t cou

nt tow

ard t

he ou

t-of-p

ocke

t limi

t.

Will

you

pay l

ess i

f you

us

e a n

etwo

rk p

rovid

er?

Yes.

See

bellc

ounty

.swhp

.org o

r ca

ll 1-8

00-3

21-7

947 f

or a

list o

f ne

twor

k pro

vider

s.

This

plan u

ses a

prov

ider n

etwor

k. Y

ou w

ill pa

y les

s if y

ou us

e a pr

ovide

r in th

e plan

’s ne

twor

k. Yo

u will

pay t

he m

ost if

you u

se an

out-o

f-netw

ork p

rovid

er, a

nd yo

u migh

t rec

eive a

bill f

rom

a pr

ovide

r for

the d

iffere

nce b

etwee

n the

prov

ider’s

char

ge an

d wha

t you

r plan

pays

(bala

nce

billin

g). B

e awa

re yo

ur ne

twor

k pro

vider

migh

t use

an ou

t-of-n

etwor

k pro

vider

for s

ome s

ervic

es

(such

as la

b wor

k). C

heck

with

your

prov

ider b

efore

you g

et se

rvice

s.

Do yo

u ne

ed a

refe

rral t

o se

e a sp

ecial

ist?

No.

You c

an se

e the

spec

ialist

you c

hoos

e with

out a

refer

ral.

* Fo

r mor

e info

rmati

on ab

out li

mitat

ions a

nd ex

cepti

ons,

see t

he pl

an or

polic

y doc

umen

t at b

ellco

unty.

swhp

.org

47

2 of

8

All c

opay

men

t and

coin

sura

nce c

osts

show

n in t

his ch

art a

re af

ter yo

ur d

educ

tible

has b

een m

et, if

a ded

uctib

le ap

plies

.

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Im

porta

nt In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u vis

it a h

ealth

ca

re p

rovid

er’s

offic

e or

clin

ic

Prim

ary c

are v

isit to

trea

t an

injur

y or il

lness

$3

0 cop

ay pe

r visi

t No

t cov

ered

No

ne

Spec

ialist

visit

$3

0 cop

ay pe

r visi

t No

t cov

ered

No

ne

Prev

entiv

e car

e/scre

ening

/ im

muniz

ation

No

char

ge

Not c

over

ed

You m

ay ha

ve to

pay f

or se

rvice

s tha

t ar

en’t p

reve

ntive

. Ask

your

prov

ider if

the

servi

ces n

eede

d are

prev

entiv

e. Th

en

chec

k wha

t you

r plan

will

pay f

or.

If yo

u ha

ve a

test

Di

agno

stic t

est (

x-ray

, bloo

d wo

rk)

No ch

arge

No

t cov

ered

So

me se

rvice

s tha

t are

not p

reau

thoriz

ed

will b

e den

ied. R

efer t

o swh

p.org

or

Custo

mer S

ervic

e at 1

-800

-321

-794

7.

Imag

ing (C

T/PE

T sc

ans,

MRIs)

20

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

If yo

u ne

ed d

rugs

to

treat

your

illne

ss o

r co

nditi

on

More

infor

matio

n abo

ut pr

escr

iptio

n dr

ug

cove

rage

is av

ailab

le at

bellc

ounty

.swhp

.org/p

harm

acy-i

nform

ation

.

Prefe

rred g

ener

ic dr

ugs

$10 c

opay

per 3

0-da

y sup

ply /

retai

l $2

0 cop

ay pe

r 90-

day s

upply

/ ma

inten

ance

. De

ducti

ble do

es no

t app

ly

Not c

over

ed

Copa

ys ar

e per

30-d

ay su

pply.

Two

co

pays

apply

for a

90-d

ay su

pply

if a

maint

enan

ce dr

ug is

obtai

ned t

hrou

gh a

Baylo

r Sco

tt & W

hite p

harm

acy O

R wh

en

using

the m

ail or

der p

resc

riptio

n ser

vice.

Sp

ecific

prev

entat

ive m

edica

tions

will

be

cove

red w

ith no

cost

to the

mem

ber.

Prefe

rred b

rand

drug

s

$40 c

opay

per 3

0-da

y sup

ply /

retai

l $8

0 cop

ay pe

r 90-

day s

upply

/ ma

inten

ance

De

ducti

ble do

es no

t app

ly

Not c

over

ed

Non-

prefe

rred g

ener

ic dr

ugs

and n

on-p

refer

red b

rand

drug

s

Less

er of

$100

or 50

% co

pay

per 3

0-da

y sup

ply / r

etail

Less

er of

$200

or 50

% co

pay

per 9

0-da

y sup

ply /

maint

enan

ce

Dedu

ctible

does

not a

pply

Not c

over

ed

Spec

ialty

drug

s Le

vel 1

– 10

% of

char

ges

Leve

l 2 –

20%

of ch

arge

s Le

vel 3

– 30

% of

char

ges

Dedu

ctible

does

not a

pply

Not c

over

ed

Some

drug

s may

requ

ire pr

ior

autho

rizati

on. 3

0-da

y sup

ply on

ly.

48

3 of

8

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Im

porta

nt In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u ha

ve o

utpa

tient

su

rger

y

Facil

ity fe

e (e.g

., amb

ulator

y su

rger

y cen

ter)

20%

after

dedu

ctible

No

t cov

ered

So

me se

rvice

s tha

t are

not p

reau

thoriz

ed

will b

e den

ied. R

efer t

o swh

p.org

or

Custo

mer S

ervic

e at 1

-800

-321

-794

7. Ph

ysici

an/su

rgeo

n fee

s 20

% af

ter de

ducti

ble

Not c

over

ed

If yo

u ne

ed im

med

iate

med

ical a

ttent

ion

Emer

genc

y roo

m ca

re

$250

copa

y; plu

s 20%

of

char

ges

$250

copa

y; plu

s 20%

of

char

ges

Copa

y waiv

ed if

episo

de re

sults

in

hosp

italiz

ation

for t

he sa

me co

nditio

n wi

thin 2

4 hou

rs.

Em

erge

ncy m

edica

l tra

nspo

rtatio

n 20

% af

ter de

ducti

ble

20%

after

dedu

ctible

No

ne

Urge

nt ca

re

$75 c

opay

per v

isit

$75 c

opay

per v

isit

If yo

u ha

ve a

hosp

ital

stay

Fa

cility

fee (

e.g., h

ospit

al ro

om)

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

Phys

ician

/surg

eon f

ees

20%

after

dedu

ctible

No

t cov

ered

If yo

u ne

ed m

enta

l he

alth,

beh

avio

ral

healt

h, o

r sub

stan

ce

abus

e ser

vices

Outpa

tient

servi

ces

$30 c

opay

per v

isit

Not c

over

ed

Some

servi

ces t

hat a

re no

t pre

autho

rized

wi

ll be d

enied

. Refe

r to s

whp.o

rg or

Cu

stome

r Ser

vice a

t 1-8

00-3

21-7

947.

Inpati

ent s

ervic

es

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

If yo

u ar

e pre

gnan

t

Offic

e visi

ts $3

0 cop

ay pe

r visi

t No

t cov

ered

Co

st sh

aring

does

not a

pply

for pr

even

tive

care

. No c

harg

e for

pren

atal v

isits;

po

stnata

l visi

ts ar

e cov

ered

at th

e sp

ecial

ist co

pay.

Child

birth/

deliv

ery p

rofes

siona

l se

rvice

s 20

% af

ter de

ducti

ble

Not c

over

ed

Some

servi

ces t

hat a

re no

t pre

autho

rized

wi

ll be d

enied

. Refe

r to s

whp.o

rg or

Cu

stome

r Ser

vice a

t 1-8

00-3

21-7

947.

Child

birth/

deliv

ery f

acilit

y se

rvice

s 20

% af

ter de

ducti

ble

Not c

over

ed

If yo

u ne

ed h

elp

reco

verin

g or

hav

e ot

her s

pecia

l hea

lth

need

s

Home

healt

h car

e $3

0 cop

ay pe

r visi

t No

t cov

ered

No

ne

Reha

bilita

tion s

ervic

es

$30 c

opay

per v

isit

Not c

over

ed

Bene

fit ma

ximum

of 20

visit

s per

calen

dar

year

, bas

ed up

on m

edica

l nec

essit

y; ad

dition

al 10

visit

s in h

ome o

nly.

49

4 of

8

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Im

porta

nt In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

Habil

itatio

n ser

vices

$3

0 cop

ay pe

r visi

t No

t cov

ered

Be

nefit

maxim

um of

20 vi

sits p

er ca

lenda

r ye

ar, b

ased

upon

med

ical n

eces

sity;

addit

ional

10 vi

sits i

n hom

e only

. Sk

illed n

ursin

g car

e 20

% af

ter de

ducti

ble

Not c

over

ed

Pre-

certif

icatio

n req

uired

. Du

rable

med

ical e

quipm

ent

50%

after

dedu

ctible

No

t cov

ered

No

ne

Hosp

ice se

rvice

s No

char

ge

Not c

over

ed

None

If yo

ur ch

ild n

eeds

de

ntal

or ey

e car

e

Child

ren’s

eye e

xam

$30 c

opay

per v

isit

Not c

over

ed

One e

xam

limit p

er ye

ar.

Child

ren’s

glas

ses

Not c

over

ed

Not c

over

ed

None

Ch

ildre

n’s de

ntal c

heck

-up

Not c

over

ed

Not c

over

ed

None

Ex

clude

d Se

rvice

s & O

ther

Cov

ered

Ser

vices

: Se

rvice

s You

r Plan

Gen

erall

y Doe

s NOT

Cov

er (C

heck

your

pol

icy o

r plan

doc

umen

t for

mor

e inf

orm

atio

n an

d a l

ist o

f any

oth

er ex

clude

d se

rvice

s.)

• Ac

upun

cture

•

Baria

tric su

rger

y •

Cosm

etic s

urge

ry

• De

ntal c

are (

Child

and A

dult)

• Inf

ertili

ty tre

atmen

t •

Long

-term

care

•

Non-

emer

genc

y car

e whe

n tra

velin

g outs

ide U

.S.

• Pr

ivate-

duty

nursi

ng

• Ro

utine

foot

care

•

Weig

ht los

s pro

gram

s

Othe

r Cov

ered

Ser

vices

(Lim

itatio

ns m

ay ap

ply t

o th

ese s

ervic

es. T

his i

sn’t

a com

plet

e list

. Plea

se se

e you

r plan

doc

umen

t.)

• Ch

iropr

actic

care

(limi

ted to

35 vi

sits p

er C

alend

ar ye

ar)

• He

aring

aids

(limi

ted to

one p

er ea

r eve

ry thr

ee ye

ars f

or co

vere

d mem

bers

18 ye

ars o

f age

or yo

unge

r) •

Routi

ne ey

e car

e (Ad

ult) (

limite

d to a

nnua

l eye

exam

cond

ucted

by a

licen

sed o

phtha

lmolo

gist o

r opto

metris

t) Yo

ur R

ight

s to

Cont

inue

Cov

erag

e: T

here

are a

genc

ies th

at ca

n help

if yo

u wan

t to co

ntinu

e you

r cov

erag

e afte

r it en

ds. T

he co

ntact

infor

matio

n for

thos

e ag

encie

s is:

Scott

& W

hite C

are P

lans,

visit s

whp.o

rg, o

r call

1-80

0-32

1-79

47; D

epar

tmen

t of L

abor

’s Em

ploye

e Ben

efits

Secu

rity A

dmini

strati

on at

1-86

6-44

4-EB

SA

(327

2) or

dol.g

ov/eb

sa/he

althr

eform

; Tex

as D

epar

tmen

t of In

sura

nce,

visit t

di.tex

as.go

v or c

all 1-

800-

578-

4677

. Othe

r cov

erag

e opti

ons m

ay be

avail

able

to yo

u too

, inc

luding

buyin

g ind

ividu

al ins

uran

ce co

vera

ge th

roug

h the

Hea

lth In

sura

nce M

arke

tplac

e. Fo

r mor

e info

rmati

on ab

out th

e Mar

ketpl

ace,

visit H

ealth

Care

.gov o

r call

1-80

0-31

8-25

96.

Your

Grie

vanc

e and

App

eals

Righ

ts: T

here

are a

genc

ies th

at ca

n help

if yo

u hav

e a co

mplai

nt ag

ainst

your

plan

for a

denia

l of a

claim

. This

comp

laint

is ca

lled a

gr

ievan

ce or

appe

al. F

or m

ore i

nform

ation

abou

t you

r righ

ts, lo

ok at

the e

xplan

ation

of be

nefits

you w

ill re

ceive

for t

hat m

edica

l clai

m. Y

our p

lan do

cume

nts al

so

prov

ide co

mplet

e info

rmati

on to

subm

it a cl

aim, a

ppea

l, or a

griev

ance

for a

ny re

ason

to yo

ur pl

an. F

or m

ore i

nform

ation

abou

t you

r righ

ts, th

is no

tice,

or as

sistan

ce,

conta

ct: S

cott &

Whit

e Car

e Plan

s, vis

it swh

p.org

, or c

all 1-

800-

321-

7947

; Tex

as D

epar

tmen

t of In

sura

nce,

visit t

di.tex

as.go

v or c

all 1-

800-

578-

4677

; Dep

artm

ent o

f La

bor’s

Emp

loyee

Ben

efits

Secu

rity A

dmini

strati

on at

1-86

6-44

4-EB

SA (3

272)

or do

l.gov

/ebsa

/healt

hrefo

rm, T

exas

Dep

artm

ent o

f Insu

ranc

e Tex

as H

ealth

Opti

ons a

t 1-

800-

252-

3439

or te

xash

ealth

optio

ns.co

m.

50

5 of

8

Does

this

plan

pro

vide M

inim

um E

ssen

tial C

over

age?

Yes

If y

ou do

n’t ha

ve M

inimu

m Es

senti

al Co

vera

ge fo

r a m

onth,

you’l

l hav

e to m

ake a

paym

ent w

hen y

ou fil

e you

r tax

retur

n unle

ss yo

u qua

lify fo

r an e

xemp

tion f

rom

the

requ

ireme

nt tha

t you

have

healt

h cov

erag

e for

that

month

. Do

es th

is pl

an m

eet t

he M

inim

um V

alue S

tand

ards

? Y

es

If you

r plan

does

n’t m

eet th

e Mini

mum

Value

Stan

dard

s, yo

u may

be el

igible

for a

prem

ium ta

x cre

dit to

help

you p

ay fo

r a pl

an th

roug

h the

Mar

ketpl

ace.

Lang

uage

Acc

ess S

ervic

es:

Span

ish (E

spañ

ol): P

ara o

btene

r asis

tencia

en E

spañ

ol, lla

me al

1-80

0-32

1-79

47.

––

––––

––––

––––

––––

––––

To se

e ex

ample

s of h

ow th

is pla

n m

ight c

over

costs

for a

sam

ple m

edica

l situ

ation

, see

the

next

secti

on. –

––––

––––

––––

––––

––––

–

51

The p

lan w

ould

be re

spon

sible

for th

e othe

r cos

ts of

these

EXA

MPLE

cove

red s

ervic

es.

6

of 8

Peg

is Ha

ving

a Bab

y (9

mon

ths of

in-n

etwor

k pre

-nata

l car

e and

a ho

spita

l deli

very)

Mana

ging

Joe’s

type

2 Di

abet

es

(a ye

ar of

routi

ne in

-netw

ork c

are o

f a w

ell-

contr

olled

cond

ition)

Mia’s

Sim

ple F

ract

ure

(in-n

etwor

k eme

rgen

cy ro

om vi

sit an

d foll

ow

up ca

re)

T

he p

lan’s

over

all d

educ

tible

$

1,250

Spe

cialis

t cop

aym

ent

$3

0

Hos

pita

l (fa

cility

) coi

nsur

ance

20%

Oth

er co

insu

ranc

e

20%

Th

is EX

AMPL

E ev

ent i

nclu

des s

ervic

es lik

e:

Sa

mpl

e Car

e Cos

ts

Sp

ecial

ist of

fice v

isits

(pre

natal

care

)

Child

birth/

Deliv

ery P

rofes

siona

l Ser

vices

Child

birth/

Deliv

ery F

acilit

y Ser

vices

Diag

nosti

c tes

ts (u

ltraso

unds

and b

lood

work)

Spec

ialist

visit

(ane

sthes

ia)

Tota

l Exa

mpl

e Cos

t $1

2,800

In

this

exam

ple,

Peg

woul

d pa

y:

Cost

Shar

ing

Dedu

ctible

s $1

,250

Copa

ymen

ts $6

10

Coins

uran

ce

$1,83

0 W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$6

0 Th

e tot

al Pe

g wo

uld

pay i

s $3

,750

T

he p

lan’s

over

all d

educ

tible

$

1,250

Spe

cialis

t cop

aym

ent

$3

0

Hos

pita

l (fa

cility

) coi

nsur

ance

20%

Oth

er co

insu

ranc

e

20%

Th

is EX

AMPL

E ev

ent i

nclu

des s

ervic

es lik

e:

Sam

ple C

are C

osts

Prim

ary c

are p

hysic

ian of

fice v

isits

(inclu

ding d

iseas

e edu

catio

n)

Diag

nosti

c tes

ts (b

lood w

ork)

Pr

escri

ption

drug

s

Dura

ble m

edica

l equ

ipmen

t (glu

cose

me

ter)

To

tal E

xam

ple C

ost

$7,40

0 In

this

exam

ple,

Joe w

ould

pay

: Co

st Sh

aring

De

ducti

bles

$0

Copa

ymen

ts $1

,550

Coins

uran

ce

$360

W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$6

0 Th

e tot

al Jo

e wou

ld p

ay is

$1

,970

T

he p

lan’s

over

all d

educ

tible

$1

,250

S

pecia

list c

opay

men

t

$30

H

ospi

tal (

facil

ity) c

oins

uran

ce

20%

Oth

er co

insu

ranc

e

20%

Th

is EX

AMPL

E ev

ent i

nclu

des s

ervic

es lik

e:

Sam

ple C

are C

osts

Emer

genc

y roo

m ca

re (in

cludin

g me

dical

supp

lies)

Diag

nosti

c tes

t (x-r

ay)

Du

rable

med

ical e

quipm

ent (

crutch

es)

Re

habil

itatio

n ser

vices

(phy

sical

thera

py)

To

tal E

xam

ple C

ost

$1,90

0 In

this

exam

ple,

Mia w

ould

pay

: Co

st Sh

aring

De

ducti

bles

$700

Co

paym

ents

$960

Co

insur

ance

$2

00

Wha

t isn’t

cove

red

Limits

or ex

clusio

ns

$0

The t

otal

Mia w

ould

pay

is

$1,86

0

Abou

t the

se C

over

age E

xam

ples

:

This

is no

t a co

st es

timat

or. T

reatm

ents

show

n are

just

exam

ples o

f how

this

plan m

ight c

over

med

ical c

are.

Your

actua

l cos

ts wi

ll be

differ

ent d

epen

ding o

n the

actua

l car

e you

rece

ive, th

e pric

es yo

ur pr

ovide

rs ch

arge

, and

man

y othe

r fac

tors.

Focu

s on t

he co

st sh

aring

am

ounts

(ded

uctib

les, c

opay

ments

and c

oinsu

ranc

e) an

d exc

luded

servi

ces u

nder

the p

lan. U

se th

is inf

orma

tion t

o com

pare

the p

ortio

n of

costs

you m

ight p

ay un

der d

iffere

nt he

alth p

lans.

Plea

se no

te the

se co

vera

ge ex

ample

s are

base

d on s

elf-o

nly co

vera

ge.

52

7 of 8

53

8 of 8

54

The Naturally Slim® program has the secret to lasting weight loss and it doesn’t include starving, counting calories or eating diet food. This simple, online program helps you change how you eat instead of what you eat. Plus, it will help you reduce your chances of getting a serious disease, like diabetes or heart disease, and increase your chance at living a longer, healthier life.

Eat what you love AND improve your health! FINALLY!

Thousands of people have completed the Naturally Slim program and achieved their goals, and most importantly, kept the weight off. You can, too!

some people can eat whatever they want and not gain weight?Finally… You don’t have to give up the foods you love!

Ever wonder why

www.naturallyslim.com

55

700% more likely to get

diabetes

300% more likely to get

heart disease

200% more likely to have

a stroke

Metabolic Syndrome

High Blood Pressure

Low HDL (good)

CholesterolHigh

TriglyceridesHigh Waist

Circumference

High Blood Sugar

What is Naturally Slim?Naturally Slim is an online program that helps you change how you eat instead of what you eat. It’s not a diet. There are no points to count. No prepackaged meals. No calories to keep track of. And, definitely no fasting.

The program teaches you mindful eating techniques and you will learn it’s possible to eat the foods you love while you lose weight and improve your health. Plus, you will reduce your chance of developing serious, chronic disease and increase your chances of living a longer, healthier life.

The Naturally Slim Foundations program includes:

■ 10 self-paced, informative, online video sessions ■ Frequent correspondence & guidance from the health counselor team ■ An online community to connect with other participants for answers & inspiration ■ A dashboard with tools to monitor your progress, learn new skills and get motivated ■ A mobile app for on-the-go access to sessions & tools to help you practice your new skills

Why is it important?Naturally Slim is about more than just losing weight. It’s about improving your overall health and reducing your chance of developing serious, chronic disease.

The development of many serious diseases isn’t random. There are certain risk factors that are generally precursors to these problems. A combination of these risk factors, called Metabolic Syndrome, can significantly raise your risk for heart disease, diabetes, stroke and many cancers.

You can be diagnosed with Metabolic Syndrome if you have three or more of these risk factors.

■ High Blood Pressure ■ Low HDL (good) Cholesterol ■ High Triglycerides ■ High Blood Sugar ■ High Waist Circumference

The good news is that you can help prevent Metabolic Syndrome through healthy lifestyle changes! That’s where Naturally Slim comes in. By following the principles taught in Naturally Slim, you can improve your health, reduce the risks associated with Metabolic Syndrome and dramatically reduce your chance of developing serious medical conditions.

Participants average 10 pounds of weight loss during the ten weeks of the program. And, most learn the skills to keep that weight off or keep losing after the program.

Learn more at www.naturallyslim.com

56

Copyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be

Virtual Care—powered by MDLIVE

SWHP-MDLIVE-Bell_07.2019

MD

Download the app.

Join for free. Visit a doctor.

General Health •

Common cold / Flu

•

Cough

•

Fever

•

Insect bites

•

Allergies

•

Diarrhea

•

Nausea / Vomiting

•

Pink eye

•

Sore throat

•

Constipation

•

Ear problems

•

Headache

Behavioral Health

•

Addictions

•

Stress / Anxiety

•

Bipolar disorders

•

Depression

•

Eating disorders

•

Grief and loss

•

Life changes

•

Panic disorders

•

Parenting issues

•

Postpartum depression

• Relationship and

marriage issues

• Trauma and PTSD

High-quality healthcare with Board-certified

Doctors 24/7,

including holidays

Online visits are

secure and convenient

Prescriptions can be sent to your pharmacy

when necessary

We’ve teamed up with MDLIVE to provide our members with access to board-certified doctors, pediatricians, licensed therapists and more—using your phone, smartphone, tablet or desktop computer. Common conditions treated:

57

Bell County FUSION Highlight Sheet

CORE PLAN Effective Date: 11/1/2019 FUSION: THE ULTIMATE CHOICESM combines dental and eye care benefits in one easy-to-administer plan. This plan combines the annual maximum between the dental and eye care plans. For the maximum:

⚫ The member can use up to $1,000 toward any covered dental expense. ⚫ The member can use up to $150 towards any covered eye care expense. ⚫ Total benefits paid between the two coverages will not exceed $1,000.

Dental Plan Summary subject to FUSION plan design listed above Plan Benefit

Type 1 100% Type 2 80% Type 3 50%

Deductible $10/visit Type 1 $50 Policy Year Type 2,3 No Family Maximum Maximum (per person) $1,000 per policy year Preventive PlusSM Included Allowance Discounted Fee Waiting Period None Orthodontia Summary - Child Only Coverage Allowance U&C Plan Benefit 50% Lifetime Maximum (per person) $1,000 Waiting Period None Dental Procedure Summary

Type 1 Type 2 Type 3 ⚫ Routine Exam (2 per benefit period) ⚫ Bitewing X-rays (2 per benefit period) ⚫ Full Mouth/Panoramic X-rays

(1 in 3 years) ⚫ Periapical X-rays ⚫ Cleaning (2 per benefit period) ⚫ Fluoride for Children 18 and under

(1 per benefit period) ⚫ Sealants (age 16 and under) ⚫ Space Maintainers

⚫ Restorative Amalgams ⚫ Restorative Composites ⚫ Endodontics (nonsurgical) ⚫ Endodontics (surgical) ⚫ Periodontics (nonsurgical) ⚫ Periodontics (surgical) ⚫ Denture Repair ⚫ Simple Extractions ⚫ Complex Extractions ⚫ Anesthesia

⚫ Onlays ⚫ Crowns

(1 in 5 years per tooth) ⚫ Crown Repair ⚫ Implants ⚫ Prosthodontics (fixed bridge; removable

complete/partial dentures) (1 in 5 years)

Current Dental Terminology © American Dental Association. Eye Care Summary subject to FUSION plan design listed above Allowances Exam Subject to maximum Lenses (per pair)

Single Subject to maximum Bifocal Subject to maximum Trifocal Subject to maximum Lenticular Subject to maximum Progressive Subject to maximum

Contacts Elective/Medically Necessary Subject to maximum

Frames Subject to maximum

Frequencies Based on date of service Exam None Lenses None Frames None

Maximum $150 Deductibles (None)

$0*

*Deductible applies to the first service received

58

Bell County FUSION Highlight Sheet

Ameritas Information We're Here to Help This plan was designed specifically for the associates of Bell County. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com. NOTICE OF CLAIM: Written notice of a claim must be given to Ameritas within 90 days after the incurred date of the services provided for which benefits are payable.

Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.

Eyewear Savings Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount.

Preventive PlusSM With this plan option, benefits for Type 1/Preventive procedures are not deducted from the plan member's annual maximum benefit. This saves the entire annual maximum for the Type 2/Basic and Type 3/Major procedures that are covered by your plan.

Dental Network Information To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at 800-487-5553.

Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered.

Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

59

Bell County FUSION Highlight Sheet

BUY-UP PLAN Effective Date: 11/1/2019 FUSION: THE ULTIMATE CHOICESM combines dental and eye care benefits in one easy-to-administer plan. This plan combines the annual maximum between the dental and eye care plans. For the maximum:

⚫ The member can use up to $1,000 toward any covered dental expense. ⚫ The member can use up to $150 towards any covered eye care expense. ⚫ Total benefits paid between the two coverages will not exceed $1,000.

Dental Plan Summary subject to FUSION plan design listed above Plan Benefit

Type 1 100% Type 2 80% Type 3 50%

Deductible $10/visit Type 1 $50 Policy Year Type 2,3 No Family Maximum Maximum (per person) $1,000 per policy year Preventive PlusSM Included Allowance 90th U&C Waiting Period None Orthodontia Summary - Child Only Coverage Allowance U&C Plan Benefit 50% Lifetime Maximum (per person) $1,000 Waiting Period None Dental Procedure Summary

Type 1 Type 2 Type 3 ⚫ Routine Exam (2 per benefit period) ⚫ Bitewing X-rays (2 per benefit period) ⚫ Full Mouth/Panoramic X-rays

(1 in 3 years) ⚫ Periapical X-rays ⚫ Cleaning (2 per benefit period) ⚫ Fluoride for Children 18 and under

(1 per benefit period) ⚫ Sealants (age 16 and under) ⚫ Space Maintainers

⚫ Restorative Amalgams ⚫ Restorative Composites ⚫ Endodontics (nonsurgical) ⚫ Endodontics (surgical) ⚫ Periodontics (nonsurgical) ⚫ Periodontics (surgical) ⚫ Denture Repair ⚫ Simple Extractions ⚫ Complex Extractions ⚫ Anesthesia

⚫ Onlays ⚫ Crowns

(1 in 5 years per tooth) ⚫ Crown Repair ⚫ Implants ⚫ Prosthodontics (fixed bridge; removable

complete/partial dentures) (1 in 5 years)

Current Dental Terminology © American Dental Association. Eye Care Summary subject to FUSION plan design listed above Allowances Exam Subject to maximum Lenses (per pair)

Single Subject to maximum Bifocal Subject to maximum Trifocal Subject to maximum Lenticular Subject to maximum Progressive Subject to maximum

Contacts Elective/Medically Necessary Subject to maximum

Frames Subject to maximum

Frequencies Based on date of service Exam None Lenses None Frames None

Maximum $150 Deductibles (None)

$0*

*Deductible applies to the first service received

60

Bell County FUSION Highlight Sheet

Ameritas Information We're Here to Help This plan was designed specifically for the associates of Bell County. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com. NOTICE OF CLAIM: Written notice of a claim must be given to Ameritas within 90 days after the incurred date of the services provided for which benefits are payable.

Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.

Eyewear Savings Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount.

Preventive PlusSM With this plan option, benefits for Type 1/Preventive procedures are not deducted from the plan member's annual maximum benefit. This saves the entire annual maximum for the Type 2/Basic and Type 3/Major procedures that are covered by your plan.

Dental Network Information To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at 800-487-5553.

Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered.

Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

61GR 6176 Secure Member 8-16

online account access for members Sign up for easier and faster digital access to your benefits information with online Explanation of Benefits (EOB).

Create your free secure member account, and you’ll have instant access to ID cards, plan benefits, your certificate of coverage, claims information and remaining benefits.

Enroll Now! Here’s How. • Go to ameritas.com to create a secure member account. • Select the "Account Access" link in the upper right corner

of the home page to see the "account access" page where you'll select the Dental/Vision/Hearing drop down.

• Choose "Secure Member Account."• On the Login page select the “Register Now” link.• Complete the New User Registration form.

Elect Electronic Explanation of Benefits (eEOB), and we'll email you whenever a claim is processed, instead of mailing you a paper statement.

To switch to eEOB and stop paper claims, select this preference on the My Profile page after you log in to your secure member account.

You can also use your online member account to access forms, read frequently asked questions or nominate your dentist to be part of our network.

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800-776-9446 ameritas.com

This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Group dental, vision and hearing care products (9000 Rev. 03-08, dates may vary by state) and individual dental and vision products (Indiv. 9000 Ed. 11-09) are issued by Ameritas Life. Some plan designs are not available in all areas. In Texas, our dental network and plans are referred to as the Ameritas Dental Network. Some states require that producers be appointed with Ameritas Life before soliciting its products. To become appointed with Ameritas Life, please call 800-659-2223. Most plans for groups with 26 or more enrolled lives are administered by Ameritas Life. Billing and eligibility for most plans with 25 or fewer enrolled lives are provided by HealthPlan Services, Inc.

Ameritas, the bison design, "fulfilling life" and product names designated with SM or ® are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. All other brands are property of their respective owners. © 2016 Ameritas Mutual Holding Company.

The online EOB lets you know about the claims processed for everyone on your plan. It is not a bill. It’s a summary of recent care charges and benefit plan payments. The easy-to-read format includes what claims were submitted, what has been paid and how your plan discounts are impacting your benefits.

Compared to paper statements, online statements are:

• more secure. A primary method of identity theft is stealing documents that are sent through the physical mail; receiving EOBs electronically is one way to reduce the risk.

• more detailed. Eliminate clutter and still receive more details on your claims than you would from a paper statement.

• convenient. You can access the secure member portal 24/7.

• faster. You don't have to wait for mail delivery.

• better for the environment. Online EOBs save trees and reduce carbon emissions.

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PRINT MEMBER ID CARD www.Ameritas.com

• Top right corner, click link, “Account Access” • Click top grey bar for “Dental/Vision/Hearing” • Click first option, “Secure Member Account” • Click “Register Now” • Continue to move through steps to register their account (it will ask for a member ID number

which is their social security number) • Once registration is complete, it will take you to the member Home Page • On the member home page, click the side bar option, “Quick Link” • Click “Print ID Card” • For assistance contact, 888.808.5080

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Prescription savingsJust for participating in our dental, vision or hearing care plans, members can save big on prescription medications through one of the world’s largest retailers. No additional cost. Only savings.

Extra Value

Our plan members, their covered dependents can save on prescription medications at over 60,000 pharmacies across the nation including CVS, Walgreens, Rite Aid and Walmart. This Rx discount is offered at no additional cost, and it is not insurance.

Participating pharmacies will give Ameritas plan members their normal health care pharmacy benefit, or the prescription discount, whichever saves them more. Even if the employees already have health insurance pharmacy benefits, they are welcome to check out this Rx discount.

Find a pharmacy near you – http://www.emsmed.com/vendors/pharmacy.aspx

Look up a price – http://www.emsmed.com/vendors/rxpricing.aspx?groupid=Ameritas

Rx Savings

Members can receive up to 65% savings on generic prescriptions, and overall average savings of 40% across brand name and generic prescription combined.

Save on frames and lensesSave up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. This is available to you without any additional cost to your plan premium.

You may receive savings on the following vision care products at Walmart Vision Centers:

• top quality frames for the entire family including today’s most popular brands.

• wide selection of lens options; all lenses come with scratch resistant coating for no additional charge.

• safety eyewear.

Guarantees

Walmart Vision Centers stand behind their products and workmanship by offering:

• 60-day frame and lens satisfaction guarantee.

• 12-month replacement guarantee on broken or damaged frames or lenses.

• lifetime adjustments and cleanings.

Rx ID Card To receive the Rx or eyewear discounts, visit ameritas.com and sign in (or create) a secure member account where you can access and print your RX savings card.

Adding Value

GR 6272 3-17

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Worldwide SupportWhen our members travel abroad, they’ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away.

Have you or a loved one ever needed urgent dental or vision care while traveling abroad? Through AXA Assistance, Ameritas now offers its dental and vision plan members access to dental or vision provider referrals when traveling outside the U.S.

Global Provider ReferralsAXA Assistance USA is part of a global organization with offices in more than 30 countries, where AXA Assistance professionals answer calls 24 hours a day. Immediately after a call comes in, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits.

AXA Assistance has been providing emergency assistance to customers and building relationships around the globe since 1959. This global organization handles over 7 million assistance cases each year.

Contact AXA Assistance USA

Toll free: (866) 662-2731

Collect from anywhere in the world: +1 (312) 935-3727

This information is provided by Ameritas Life Insurance Corp. [Ameritas Life]. Group dental, vision and hearing care products [9000 Rev. 03-16, dates may vary by state] and individual dental and vision products [Indiv. 9000 Ed. 07-16] are issued by Ameritas Life. Some plan designs are not available in all areas. In Texas, our PPO network and plans are referred to as the Ameritas Dental Network. Some states require that producers be appointed with Ameritas Life before soliciting its products. To become appointed with Ameritas Life, please call 800-659-2223. Most plans for groups with 26 or more enrolled lives are administered by Ameritas Life. Billing and eligibility for most plans with 25 or fewer enrolled lives are provided by HealthPlan Services, Inc.

Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. All other brands are property of their respective owners.

© 2017 Ameritas Mutual Holding Company.

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prescription savings

Just for participating in our dental, vision or hearing care plans, members can save big on prescription medications through one of the world’s largest retailers. No additional cost. Only savings.

Extra ValueOur plan members, their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam’s Club pharmacy nationwide. This Rx discount is offered at no additional cost, and it is not insurance.

Even if employees already have health insurance pharmacy benefits, they are welcome to check out this Rx discount. Walmart and Sam’s Club pharmacies can see which saves more and give members the better deal if members bring in their current health insurance ID card and prescription.

Rx ID CardTo receive the Walmart Rx discount, members present an Rx discount savings ID card that contains all of the information for the pharmacy staff. To get one, members visit ameritas.com and sign into (or create) a secure member account. Once signed in, they can print the online Rx discount savings ID card.

Rx SavingsOur valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam’s Club pharmacy across the nation. This Rx discount is offered at no additional cost and it is not insurance. Save on hundreds of generic drug prescriptions at the everyday low price of $4, as well as, 40% on other generic prescriptions and 10-15% on most name brand drug prescriptions.

Secure AccountIn addition to the Rx discount savings ID card, members can access their benefit summary, certificate of coverage and pending/paid claims. Benefits administrators with eServices also will have access to the Rx discount savings ID card to assist members without Internet access. With eServices, benefits administrators can enjoy accurate plan administration and billing — all at no cost. Join us online today!

Did You Know?From 1999 to 2009, the number of prescriptions purchased in the U.S. increased 39%, while the population only grew 9%.

Retail prescription prices have increased an average of 3.6% annually between 2000 and 2009, much faster than the average inflation rate of 2.5%.

source: www.kaiseredu.org, costs and spending, prescription drug costs

GR 6273 10-14

This information is provided by Ameritas Life Insurance Corp. [Ameritas Life]. Group dental, vision and hearing care products [9000 Rev. 03-08, dates may vary by state] and individual dental and vision products [Indiv. 9000 Ed. 11-09] are issued by Ameritas Life. Some plan designs are not available in all areas. In Texas, our PPO network and plans are referred to as the Ameritas Dental Network. Some states require that producers be appointed with Ameritas Life before soliciting its products. To become appointed with Ameritas Life, please call 800-659-2223. Most plans for groups with 26 or more enrolled lives are administered by Ameritas Life. Billing and eligibility for most plans with 25 or fewer enrolled lives are provided by HealthPlan Services, Inc.

Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life or its affiliate Ameritas Holding Company. All other brands are property of their respective owners. © 2014 Ameritas Mutual Holding Company.

800-776-9446 ameritas.com

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FAQ about the Rx discount savings offer

What is the Rx Discount?It helps our plan members save money on prescription medications through the use of an ID card.

At the point of sale, members simply present the ID card at any Walmart or Sam’s Club pharmacy nationwide.

What ID Card Should I Use?Ameritas dental, vision and hearing care plan members will need to get the online Rx discount savings ID card by visiting ameritas.com and signing into (or creating) a secure member account. (No Internet? Request an Rx ID card through your benefits administrator, or call Ameritas at 800-487-5553.)

Who Needs Discount Prescription Drugs?Anyone with limited or no prescription drug coverage can benefit. Instead of paying full price for medication, members can save money on prescription drugs for themselves, their covered dependents and even their pets.

Members who already have an existing pharmacy benefit may still see savings on medications that are not included in their plan. Walmart and Sam’s Club pharmacies will give members their existing pharmacy benefit, or the Rx savings discount through Ameritas, whichever saves members the most money. For comparisons, members will need to bring in their current health insurance ID card and prescription.

GR 6274 10-14

What Kind of Savings Are We Talking About?Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam’s Club pharmacy across the nation. This Rx discount is offered at no additional cost and it is not insurance. Save on hundreds of generic drug prescriptions at the everyday low price of $4, as well as, 40% on other generic prescriptions and 10-15% on most name brand drug prescriptions.

Additional Advantages:1. Unlimited use

2. Rx ID card may be used by all covered dependents, including pets

3. The vast majority of all prescription drugs are discounted

4. Generic substitution when allowed by prescribing physician

5. Top-quality, major-pharmacy mail-order service

6. Call Walmart’s low-price network at 800-972-0943 to verify prices

7. No waiting periods

8. No claim forms to file

Disclosures Regarding the Walmart Prescription Savings Program: This discount plan is NOT insurance or a Medicare prescription drug plan. Members are obligated to pay 100% of the prescription cost to the pharmacy at the point of sale and the plan does not pay pharmacies for prescription drugs provided to members. The Walmart Prescription Savings Program provides prescription drug discounts to members at participating pharmacies only. Drug prices fluctuate frequently and the plan’s pricing tool (where available) is for informational purposes only.

This information is provided by Ameritas Life Insurance Corp. [Ameritas Life]. Group dental, vision and hearing care products [9000 Rev. 03-08, dates may vary by state] and individual dental and vision products [Indiv. 9000 Ed. 11-09] are issued by Ameritas Life. Some plan designs are not available in all areas. In Texas, our PPO network and plans are referred to as the Ameritas Dental Network. Some states require that producers be appointed with Ameritas Life before soliciting its products. To become appointed with Ameritas Life, please call 800-659-2223. Most plans for groups with 26 or more enrolled lives are administered by Ameritas Life. Billing and eligibility for most plans with 25 or fewer enrolled lives are provided by HealthPlan Services, Inc.

Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life or its affiliate Ameritas Holding Company. All other brands are property of their respective owners. © 2014 Ameritas Mutual Holding Company.

800-776-9446 ameritas.com

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save on frames and lenses

And if you're an Ameritas plan member with our group dental, Vision Perfect®, FUSION, LASIK Advantage® or SoundCare® coverage, you can save — up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. This is available to you without any additional cost to your plan premium.

You may receive savings on the following vision care products at Walmart Vision Centers: • top quality frames for the entire family including today’s most

popular brands. • wide selection of lens options; all lenses come with scratch

resistant coating for no additional charge.

• safety eyewear.

GR 6435 1-15

Vision prescriptions acceptedYou may also bring in your current vision prescription to purchase eyewear frames and lenses.

GuaranteesWalmart Vision Centers stand behind their products and workmanship by offering: • 60-day frame and lens satisfaction guarantee. • 12-month replacement guarantee on broken or damaged

frames or lenses. • lifetime adjustments and cleanings.

Savings cardVisit ameritas.com and sign in (or create) a secure member account where you can access and print an eyewear frames and lenses savings card.

We want you to save money the next time you shop for eyewear frames and lenses at Walmart.

This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Group dental, vision and hearing care products (9000 Rev. 03-08, dates may vary by state) and individual dental and vision products (Indiv. 9000 Ed. 11-09) are issued by Ameritas Life. Some plan designs are not available in all areas. In Texas, our dental network and plans are referred to as the Ameritas Dental Network. Some states require that producers be appointed with Ameritas Life before soliciting its products. To become appointed with Ameritas Life, please call 800-659-2223. Most plans for groups with 26 or more enrolled lives are administered by Ameritas Life. Billing and eligibility for most plans with 25 or fewer enrolled lives are provided by HealthPlan Services, Inc.

Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. All other brands are property of their respective owners. © 2015 Ameritas Mutual Holding Company.

800-776-9446 ameritas.com

69

What is the Eyewear Frames and Lenses Savings?It provides our plan members savings up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. This savings arrangement is available to group members at no additional cost to their plan premium.

The eyewear savings cannot be combined with any other insurance, coupon or promotion.

What ID Card Can I Use?Members can visit ameritasgroup.com and sign in (or create) a secure member account where they can access and print an eyewear frames and lenses savings card. (No Internet? Members can request an ID card through their benefits administrator, or call Ameritas at 800-487-5553.)

When making an appointment at a Walmart Vision Center, members must identify having access to eyewear savings through their Ameritas plan and present the eyewear savings ID card.

This information is provided by Ameritas Life Insurance Corp. [Ameritas Life]. Group dental, vision and hearing care products [9000 Rev. 03-08, dates may vary by state] and individual dental and vision products [Indiv. 9000 Ed. 11-09] are issued by Ameritas Life. Some plan designs are not available in all areas. In Texas, our PPO network and plans are referred to as the Ameritas Dental Network. Some states require that producers be appointed with Ameritas Life before soliciting its products. To become appointed with Ameritas Life, please call 800-659-2223. Most plans for groups with 26 or more enrolled lives are administered by Ameritas Life. Billing and eligibility for most plans with 25 or fewer enrolled lives are provided by HealthPlan Services, Inc.

Ameritas, the bison symbol, and company names designated with SM or ® are service marks or registered service marks of Ameritas Life or Ameritas Mutual Holding Company. Walmart brand names, symbols and taglines are property of Walmart Stores, Inc. © 2013 Ameritas Mutual Holding Company.

800-776-9446 ameritasgroup.com

GR 6436 Rev. 7-13

Who Do Members Call for Insurance Benefit Questions?If members have questions regarding insurance benefits, they can call Ameritas toll free at 800-487-5553.

Is a Vision Exam Required to Receive the Eyewear Savings?No. Members may bring in their current vision prescription from another vision care provider.

How to Find a Walmart Vision Center?Vision Centers are located in more than 2,500 Walmart stores nationwide. To find a Walmart location nearby, visit walmart.com/cservice/ca_storefinder.gsp.

FAQ about eyewear frames and lenses savings

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Accident Insurance Accidents can happen anytime, anywhere.Accidents are usually followed by a series of bills. Even if you have good insurance, you may still have to cover out-of-pocket costs, such as:

� Doctor bills � Ambulance fees � Hospital expenses

Accident insurance from Colonial Life & Accident Insurance Company can help protect you, your spouse and your dependent children from the unexpected expenses of an accident.

Features of Colonial Life’s Accident Insurance: � You are paid benefits to help you with the care and treatment of a covered accidental injury. � Your benefits are paid directly to you (unless you specify otherwise). � You are paid benefits regardless of any other insurance you may have with other insurance companies. � You can take your coverage with you if you change jobs or retire.

Disability InsuranceIf you got sick or hurt and couldn’t work, how long could you go without a paycheck? In today’s economy, it’d be difficult losing just one paycheck. But a disability could have you out of work for days, weeks, months or even a year:

Disability insurance from Colonial Life & Accident Insurance Company can help protect your income, so you can maintain your way of life.

Features of Colonial Life’s Accident Insurance: � You’re paid regardless of any other insurance you may have with other insurance companies. � Benefits are paid directly to you, unless you specify otherwise. � You may choose the amount of your disability benefits to meet your needs, subject to income. � You can take your coverage with you if you change jobs or leave your employer.

Colonial LifeVoluntary Insurance

Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor.

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Cancer Insurance How will you pay for what your health insurance won’t? If diagnosed with cancer, would you have the money to cover:

� Out-of-network treatments � Second opinions � Rehabilitation � Travel and lodging � Child care expenses

Cancer insurance from Colonial Life & Accident Insurance Company helps guard against financial hardship if you or a loved one is diagnosed with cancer.

Features of Colonial Life’s Cancer Insurance: � Helps pay some of the direct and indirect costs related to cancer diagnosis and treatment. � Helps pay for expenses health insurance may not cover, such as deductibles and coinsurance. � Pays an annual benefit for specified cancer screening tests.

Critical Illness InsuranceAre you prepared for the cost of an illness? If you were to suffer a heart attack, stroke or other critical illness, would you have the money to cover:

� Deductibles and coinsurance � Home health care needs � Travel and lodging � Lost income � Rehabilitation � Child care

Even those of us who plan for the unexpected with life, disability and health insurance may discover that some critical illness expenses can still remain unpaid. Without adequate protection, you could have to pull from savings or rely on other financial sources in your time of need.

Critical illness insurance from Colonial Life & Accident Insurance Company helps preserve your lifestyle in the event of a specified critical illness. It provides benefits that you can use however you like.

Features of Colonial Life’s Critical Illness Insurance: � Pays a benefit if you are diagnosed with a covered specified critical illness. � Coverage is available for you and your covered dependents.

Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor.

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Hospital Confinement Indemnity Insurance You may have health insurance, but are you really covered? Health insurance may cover:

� Hospital fees � Outpatient surgery � Doctor/ER visits � Prescriptions

It may not cover: � Deductibles � Co-payments � Coinsurance

Hospital confinement indemnity insurance from Colonial Life & Accident Insurance Company can help you with unexpected health care expenses that your medical insurance may not cover. It pays an indemnity benefit for each covered hospital confinement. Plans also include a wellness testing benefit, which helps reimburse you for a portion of the tests you would normally have each year.

Features of Colonial Life’s Hospital Confinement Indemnity Insurance: � Benefits are paid directly to you, unless you specify otherwise. � Benefits are paid regardless of any other insurance you may have with other insurance companies. � You can take your coverage with you if you change jobs or leave your employer. � Coverage is guaranteed renewable as long as premiums are paid when they are due. � Coverage is available for you, your spouse and your dependent children.

Term Life InsuranceLife insurance protection when you need it most? Life insurance needs change as life circumstances change. You may need different coverage if you’re:

� Getting married � Buying a home � Having a child � Taking on additional debt

Term life insurance from Colonial Life & Accident Insurance Company provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages where obligations are higher, such as while children are young. It’s also a good option for families on a tight budget – especially since you can convert it to a permanent cash value plan later.

Benefits of Colonial Life’s Term Life Insurance: � Provides a benefit for the beneficiary that is typically free from income tax. � The policy’s Accelerated Death Benefit can pay a percentage of the death benefit if the insured is diagnosed with

a terminal illness. � You can take it with you if you change jobs or retire. � Convert to a Colonial Life cash value life insurance plan, with no proof of good health, to age 75. � Spouse and dependent children coverage is available.

Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor.

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Whole Life InsuranceLife insurance that comes with guarantees … because life doesn’tWhole life insurance from Colonial Life & Accident Insurance Company provides guaranteed features – cash value accumulation, premium rates and death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.

Guaranteed protection: Offers lifetime protection with a guaranteed death benefit that will not change as long as premiums are paid when due.

Guaranteed premiums: Promises a level premium that stays the same from the day you purchase the policy.

Guaranteed cash value: Guarantees the cash value amount – which accumulates on a tax-deferred basis.

Features of Colonial Life’s Whole Life Insurance: � Provides a benefit for the beneficiary that is typically free from income tax. � Three option dates to purchase additional coverage with no proof of good health required if you are age 55 or younger

at the time of purchase. � The policy’s Accelerated Death Benefit can provide a percentage of the death benefit if the insured is diagnosed with

a terminal illness. � $3,000 immediate claim payment as an advance of the death benefit, paid to the designated beneficiary.

Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor.

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64

How to file a wellness claim� The quickest way to receive the applicable benefits for

your health screening services is to file a wellness claim via our secure My Colonial Life for Policyholders section of ColonialLife.com. By filing through the website, you can receive your benefit in a matter of days.

� For wellness screenings within 12 months of the date you are filing the claim, go to ColonialLife.com, log in tothe My Colonial Life policyholder section, and click on File a Wellness Claim Online. Or you may use the automated customer service center at 1-800-325-4368.

� For wellness screenings over 12 months from the date you are filing the claim, you’ll be directed to print out a paper claim form and complete it manually. Fill it out, and submit the claim as the form instructs. Be sure to review and sign all pages where indicated.

How to file disability claims� Where indicated on the form, be sure to:

– Have the doctor verify the dates of disability and furnish dates of treatment.

– Have the employer confirm the dates missed from work.

� Read and sign the claims authorization page. We cannot obtain additional information from your doctor without proper consent.

� Submit your claim:

– Fax the completed form to 1-800-880-9325. Include your name and Social Security number on each page of your fax as indicated. If you fax the claim, you do not need to mail the original document to us; keep it for your records.

OR

– Mail the completed forms to Colonial Life (see the Contact us section of this document).

Service guide for policyholders

The quickest, easiest way to manage your business with us is through the My Colonial Life policyholder section of ColonialLife.com. Join now for convenient access to your policy and claims information.

If you’re not already signed up:

� Visit ColonialLife.com, and click Loginon the home page.

� Click Request access to our policyholder or plan administrator website, and you’ll be directed to a sign-up page.

n File a wellness claim.

n Check on the status of your claim.

n Check your policy information.

n Download claim and service forms.

n Update your contact information.

As a My Colonial Life member, you can:

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How to file other claims � On the Claims page of the My Colonial Life site, click on File All

Other Types of Claims, and choose the form you need for your specific claim.

� Complete the form that applies to your specific claim. Be sure the information includes a diagnosis from your doctor, along with copies of any appropriate medical bills, if required. Make sure you sign and date the certification and the authorization portion of the claim form.

Optional servicesThe first page of Colonial Life’s claim forms explains optional services that you can request by initialing the blanks provided.

The options include authorizing Colonial Life to:

� Release information to your benefits representative, plan administrator or family member.

� Communicate claims information via electronic messaging toyour home phone number.

Processing your claim� When we receive information regarding your claim, you will be

notified by telephone or email.

� If you select the electronic messaging option, you will receive a call when the claim is processed.

� We will notify you by letter if we need any additional informationfrom your doctor or any other source(s). We welcome your assistance in encouraging your doctor to provide the needed information as quickly as possible.

� If your claim is for a sickness or health condition, we may need to contact your doctor or request copies of medical records to confirm information, which may lengthen the claim processing time.

� Our goal is to provide prompt and accurate claims service. Remember, you can always check the status of your claim via the My Colonial Life site.

Ongoing claimsTotal disability benefits provided by your coverage are based on disability information submitted on your claim form.

Because Colonial Life cannot pay benefits for time you have not yet missed from work, you may be asked to provide verification of your ongoing disability and the dates you are unable to work. Your doctor and employer must confirm all disability dates. Please include medical treatment dates on your claim form. ©2014 Colonial Life & Accident Insurance Company

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

5-14 | 43233-36

Contact usOnline

Log in to the My Colonial Life website to contact us by email.

Telephone 1-800-325-4368

Contact Center representatives are available Monday through Friday, 8 a.m. – 8 p.m. EST.

Automated service information is available every day throughout the year.

Please have your Social Security or policy number ready when you call.

Hearing-impaired customers Customers with a Telecommunications

Device for the Deaf (TDD) should call 803-798-4040.

Mailing addressColonial Life Contact Center

P.O. Box 100195, Columbia, SC 29202-3195

ColonialLife.com

Important remindersn Be sure to view the claims videos on the

Claims page of the My Colonial Life site, for quick tips on how to complete your claim form quickly, easily and correctly.

n Be sure to complete all sections of the claim form. Incomplete information may cause a delay in the resolution of your claim.

n When you mail the claim form or other information, please keep a copy of your information for your records.

n If you want us to send any applicable claim benefits by overnight delivery and deduct the fee from your claim payment, initial the overnight line in the “Optional Service” section of the claim form.

76

Medicare D Notice

Important Notice from Bell County About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Bell County and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can getthis coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like anHMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least astandard level of coverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.

2. Bell County has determined that the prescription drug coverage offered by the Bell County MedicalPlan is, on average for all plan participants, expected to pay out as much as standard Medicareprescription drug coverage pays and is therefore considered Creditable Coverage. Because yourexisting coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (apenalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Bell County coverage will not be affected. Your current coverage pays for other health expenses in addition to prescription drug. Please see the Medical Benefit Plan in this book for specific details about the prescription drug coverage.

If you enroll in a Medicare prescription drug plan, you and your eligible dependents will be eligible to receive all of your current health and prescription drug benefits and your coverage will coordinate with Medicare.

If you do decide to join a Medicare drug plan and drop your current Bell County coverage, be aware that you and your dependents may not be able to get this coverage back.

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this infor-mation collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data re-sources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Medicare D Notice

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Bell County and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Bell County changes. You also may request a copy of this notice at any time.

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: • Visit www.medicare.gov• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the“Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: November 2019 Name of Entity/Sender: Bell County Contact Office: Human Resources Address: 101 E. Central Avenue, 3rd Floor

Belton, TX 76513 Phone Number: 254-933-5111

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this infor-mation collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data re-sources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

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We may use and share your information as we:

• Help manage the health care treatment you receive• Run our organization• Pay for your health services• Administer your health plan• Help with public health and safety issues• Do research• Comply with the law• Respond to organ and tissue donation requests and

work with a medical examiner or funeral director• Address workers’ compensation, law enforcement,

and other government requests• Respond to lawsuits and legal actions

➤ See pages 3 and 4 for more information on these uses and disclosures

You have the right to: • Get a copy of your health and claims records• Correct your health and claims records• Request confidential communication• Ask us to limit the information we share• Get a list of those with whom we’ve shared

your information• Get a copy of this privacy notice• Choose someone to act for you• File a complaint if you believe your privacy

rights have been violated

➤ See page 2 for more information on these rights and how to exercise them

Our Uses and

Disclosures

Your Rights

➤ See page 3 for more information on these choices and how to exercise them

You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends• Provide disaster relief• Market our services and sell your information

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.

Your Information. Your Rights.Our Responsibilities.

Your Choices

Notice of Privacy Practices • Page 1

Bell County Human Resources DepartmentPO Box 454, Belton, Texas 76513Phone: 254-933-5111

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Notice of Privacy Practices • Page 2

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Your Rights

Get a copy of your health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

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Notice of Privacy Practices • Page 3

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

Your Choices

Help manage the health care treatment you receive

• We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health services

• We can use and disclose your health information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan

• We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Our Uses and

Disclosures

continued on next page

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Notice of Privacy Practices • Page 4

Help with public health and safety issues

• We can share health information about you for certain situations such as: • Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety

Do research • We can use or share your information for health research.

Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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Notice of Privacy Practices • Page 5

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

This Notice of Privacy Practices applies to the following organizations.

Effective Date of Notice 11/01/2019.

Bell County

Bell CountyHuman Resources DepartmentPO Box 454, Belton, Texas 76513Phone: 254-933-5111

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CHIPRA Notice

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Important Information

The Women’s Health and Cancer Rights Act The Women’s Health and Cancer Rights Act of 1998 requires group health plans that provide coverage for a mastectomy to provide coverage for certain reconstructive services. This law also requires that written notice of the availability of the coverage be delivered to all plan participants upon enrollment and annually thereafter. This language serves to fulfill that requirement for this year. These services include:

Reconstruction of the breast upon which themastectomy has been performed;

Surgery / reconstruction of the other breast toproduce a symmetrical appearance;

Prostheses; and Treatment for physical complications during all stages

of mastectomy, including lymphedemas.

In addition, the plan may not: Interfere with a participant’s rights under the plan to

avoid these requirements; or Offer inducements to the healthcare provider, or

assess penalties against the provider, in an attempt tointerfere with the requirements of the law.

However, the plan may apply deductibles, coinsurance, and co-payments consistent with other coverage provided by the plan.

Newborns Act Disclosure Group health plans and health insurance issuers generally may not, under Federal Law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal Law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours or 96 hours as applicable. In any case, plans and issuers may not, under Federal Law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours or 96 hours.

Summary of Material Modification This Summary of Material Modification (SMM) describes changes to the Bell County Plan and supplements the Summary Plan Description (SPD) for the plan. The effective date of each of these changes is November 1st, 2019. You should read this SMM very carefully and retain this document with your copy of the SPD for future reference.

This book highlights some of the main features of your benefit programs, but does not include all plan rules, features, limitations or exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be any inconsistencies between this book and the legal plan documents, the plan documents are the final authority. Bell County reserves the right to change or discontinue its benefit plans at any time.

Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or you dependents in this plan if your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request and complete enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request and complete enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

Special enrollment rights also may exist in the following circumstances:

If you or your dependents experience a loss ofeligibility for Medicaid or a state Children’s HealthInsurance Program (CHIP) coverage and you requestenrollment within 60 days after that coverage ends; or

If you or your dependents become eligible for a statepremium assistance subsidy through Medicaid or astate CHIP with respect to coverage under this planand you request enrollment within 60 days after thedetermination of eligibility for such assistance.

Note: The 60 day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 31 days period applies to most special enrollments.

To request special enrollment or obtain more information, contact Human Resources at Bell County.

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Notes:

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Notes:

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