City of Nacogdoches 2021 Enrollment Guide

EMPLOYEE BENEFITS
ENROLLMENT GUIDE
Plan Year 2021-2022
Effective October 1, 2021 to September 30, 2022
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OPEN ENROLLMENT!
August 3 to August 20
DEADLINE TO
ENROLL IS
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CONTENTS
04 Benefits Overview
06 Medical Insurance
13 Flexible Spending Accounts
17 Dental Insurance
19 Vision Insurance
21 Basic Life and Accidental Death & Dismemberment Insurance
24 Voluntary Life and Accidental Death & Dismemberment Insurance
26 Long Term Disability Insurance
28 Employee Assistance Program
29 Open Enrollment Instructions
31 Important Contacts
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BENEFITS OVERVIEW
ENROLLMENT
You can enroll in benefits or change your elections at the following times:
• 30 days prior to your initial eligibility date (as a newly hired employee)
• During the annual benefits open enrollment period
• Within 30 days of experiencing a qualifying life event
BENEFIT OPTIONS
We offer a comprehensive benefits package consisting of:
• Medical Insurance
• Flexible Spending Accounts
• Dental Insurance
• Vision Insurance
• Basic Life and Accidental Death & Dismemberment Insurance
• Voluntary Life and Accidental Death & Dismemberment Insurance
• Long Term Disability Insurance
• Employee Assistance Program
4

BENEFITS OVERVIEW
ELIGIBILITY
Full-time employees working at least 30 hours per week are eligible for
benefits on the first of the month following your date of employment. Many of
the plans offer coverage for eligible dependents, including:
• Your legal spouse
• Your children to age 26, regardless of student, marital, or tax-dependent
status (including stepchild, legally adopted child, a child placed with you for
adoption, or a child for whom you are the legal guardian)
• Your dependent children over age 26 who are physically or mentally unable
to care for themselves
CHANGING BENEFITS AFTER OPEN ENROLLMENT
You may pay your portion of your select coverages, and fund the flexible
spending accounts, on a pre-tax basis. Thus, due to IRS regulations, once you
have made your elections for the plan year, you cannot change your benefits
until the next annual open enrollment period. The only exception is if you
experience a qualifying event, and election changes must be consistent with
your life event.
To request a benefits change, notify Human Resources within 31 days of the
qualifying life event. Change requests submitted after 31 days cannot be
accepted. You may need to provide proof of the life event.
Qualifying life events include, but are not limited to:
• Marriage, divorce, or legal separation
• Birth or adoption of an eligible child
• Death of your spouse or covered child
• Change in your spouse’s work status that affects his or her benefits
• Change in your child’s eligibility for benefits
• Qualified Medical Child Support Order
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MEDICAL INSURANCE
CARRIER: BLUE CROSS BLUE SHIELD
Please refer to the official plan documents for additional information on coverage
and exclusions.
COVERED BENEFITS
BASE PLAN
IN-NETWORK
NON-NETWORK
Calendar Year Deductible - Individual/Family
Per Admission
$3,000/$6,000
None
Three month deductible carryover applies
$6,000/$12,000
None
Three month deductible carryover applies
Out of Pocket Maximum - Individual/Family $7,900/$15,800 $10,000/$20,000
Coinsurance 70 / 30% 50 / 50%
Preventive Care 100% of allowable amount 70% of allowable amount after deductible
Primary Office Visit 100% of allowable amount after $45 copay 70% of allowable amount after deductible
Specialist Office Visit 100% of allowable amount after $45 copay 70% of allowable amount after deductible
Virtual Visit MDLive (Medical or Behavioral Health) 100% of allowable amount N/A
Diagnostic Test (x-ray, bloodwork) 100% of allowable amount 70% of allowable amount after deductible
Imaging (CT/PET scans, MRI’s) 70% of allowable amount after deductible 50% of allowable amount after deductible
Urgent Care 100% of allowable amount after $75 copay 70% of allowable amount after deductible
Inpatient Services
Penalty for failure to preauthorize
70% after Calendar Year Deductible
None
50% of allowable amount after deductible
$250
Emergency Room
70% of allowable amount after $400 copay for facility; copay waived if admitted
Physician charges: 70% after calendar year deductible
RETAIL PHARMACY In-Network Non-Network
Generic
Preferred
Non-Preferred
Specialty Drugs
$20 copay
$50 copay
$75 copay
$150 copay
80% of allowable amount minus applicable copay
COVERAGE LEVEL
MONTHLY EMPLOYEE COST
Employee Only
No cost to employee; paid by City
Employee & Spouse $497.05
Employee & Child(ren) $454.38
Employee & Family $867.08
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MEDICAL INSURANCE
CARRIER: BLUE CROSS BLUE SHIELD
COVERED BENEFITS
Buy-Up PLAN
IN-NETWORK
NON-NETWORK
Calendar Year Deductible - Individual/Family
Per Admission
$1,500/$3,000
None
Three month deductible carryover applies
$3,000/$6,000
None
Three month deductible carryover applies
Out of Pocket Maximum - Individual/Family $7,150/$14,300 $10,000/$20,000
Coinsurance 80 / 20% 60 / 40%
Preventive Care 100% of allowable amount 70% of allowable amount after deductible
Primary Office Visit 100% of allowable amount after $45 copay 70% of allowable amount after deductible
Specialist Office Visit 100% of allowable amount after $45 copay 70% of allowable amount after deductible
Virtual Visit MDLive (Medical or Behavioral Health) 100% of allowable amount N/A
Diagnostic Test (x-ray, bloodwork) 100% of allowable amount 70% of allowable amount after deductible
Imaging (CT/PET scans, MRI’s) 80% of allowable amount after deductible 60% of allowable amount after deductible
Urgent Care 100% of allowable amount after $65 copay 70% of allowable amount after deductible
Inpatient Services
Penalty for failure to preauthorize
80% of allowable amount after deductible
None
60% of allowable amount after deductible
$250
Emergency Room
80% of allowable amount after $300 copay for facility, copay waived if admitted
Physician charges 80% after calendar year deductible
RETAIL PHARMACY In-Network Non-Network
Generic
Preferred
Non-Preferred
Specialty Drugs
$20 copay
$50 copay
$75 copay
$150 copay
80% of allowable amount minus applicable copay
COVERAGE LEVEL
MONTHLY EMPLOYEE COST
Employee Only $68.20
Employee & Spouse $650.69
Employee & Child(ren) $599.75
Employee & Family $1,092.35
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REMINDER:
Effective as of 10/1/2019, the city moved to the Performance Formulary Drug Plan. The
plan is designated to drive members to over- the counter products, low cost generic
drugs, or lower cost preferred brand-name drugs.
For some drugs, prior authorizations and step therapy are required.
Compound drugs are excluded. Coverage is only available through an exception review
process only to ensure medical necessity.
Proton Pump Inhibitors (i.e. Nexium, Prilosec, Omeprazole, etc) are excluded due to the
abundance of over-the-counter products.
Non-sedating Antihistamines (i.e. Claritin, Zyrtec, Allegra, loratadine, etc) are excluded
due to the abundance of over-the-counter products
To see if your prescriptions are covered:
1. Go to www.myprime.com
● click “Find medicines”.
● Register as a user.
● If asked for your drug list, choose “Performance-Annual Drug List”.
● You may also call BCBS at 1-800-521-2227
1. You can Contact
● BXS Insurance at 936-564-1713
● Human Resources at 936-559-2567
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VIRTUAL VISITS / MDLIVE
When it comes to healthcare, access
is important. You want care that is
convenient, high-quality and
low-cost. But depending on your
condition, going to your personal
physician or an urgent care clinic
might not be your best option. We
are proud to offer telemedicine /
virtual visits.
TREATED THROUGH TELEMEDICINE
Allergies
Cold & Flu Symptoms
Cough
Ear Infection
Pink Eye
Prescription Refills
Respiratory Infection
Sinus Problems / Nasal Congestion
Urinary Tract Infection
And more!
NOT TREATED THROUGH TELEMEDICINE
Sprains, broken bones or injuries requiring bandaging
Anything that needs a hands-on exam
Anything that needs a lab test or X-ray
Chronic conditions
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FLEXIBLE SPENDING ACCOUNTS
Why not use pre - tax dollars to pay for medical co-pays,
prescriptions, and/or daycare fees, thereby reducing your
taxable income and increase your tax- home pay? It’s a
no-brainer.
The pre-tax advantage of a Flexible Spending Account (FSA) allow
you to save up to 30% on your eligible healthcare and/or dependent
care expenses every year. Consider how much you spend on these
costs for you and your qualified dependents in one year and how
much you could save by using pre-tax dollars.
How it Works
Flexsystem FSA is offered through your employer and is
administered by TASC. When you choose to enroll in a FlexSystem
Healthcare FSA and/ or Dependent Care FSA, you determine the
dollar amount you want to contribute to each account based on
your estimated expenses for the upcoming Plan Year. Your
contributions will be deducted in equal amounts from each
paycheck, pre-tax, throughout the Plan Year.
The more you contribute to these accounts, the lower you reduce
your taxable gross salary. And with less taxes, your take- home
pay increases!
Your total annual Healthcare FSA contribution amount is available
immediately at the start of the Plan Year. Dependent Care FSA
funds are available up to the current account balance only.
Online Enrollment and Contributions
Annual FSA contributions are set by your employer, but are limited
to the IRS maximums per Plan Year. View current IRS limits at:
www. tasconline.com/benefits-limits/
2021 Limits
Healthcare FSA - $2,750
Dependent Care FSA - $5,000
0
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FLEXIBLE SPENDING ACCOUNTS
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FLEXIBLE SPENDING ACCOUNTS
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FLEXIBLE SPENDING ACCOUNTS
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DENTAL INSURANCE
CARRIER: BLUE SHIELD BLUE CROSS
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.bcbstx.com.
● Be sure to ask for a pre-treatment estimate.
● Out-of-network providers can balance bill, or bill you for the difference between
the provider’s charge and the allowed amount.
ELECTION
MONTHLY EMPLOYEE COST
Employee Only $0.00
Employee & Spouse $30.97
Employee & Child(ren) $40.80
Employee & Family $82.02
CONTRACTING DENTIST
NON-CONTRACTING DENTIST / UCR 90th
Annual Calendar Deductible
(waived for preventive)
$50 per person, $150 per family $50 per person, $150 per family
Annual Maximum $1,000 $1,000
Annual Maximums are combined for preventive, basic, and major services.
Lifetime Orthodontic Max $1,000 $1,000
Orthodontic Coverage is available for dependent children up to age 19.
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DENTAL INSURANCE
CONTRACTING DENTIST
NON-CONTRACTING
DENTIST
Diagnostic Services
Oral evaluations
Radiographs
Films
Preventive Services
Prophylaxis (cleanings)
Topical fluoride applications
Sealants
Space maintainers
Basic Services
Amalgams
Resin-based composite restorations
Non-surgical extractions
Deep sedation / general anesthesia
Palliative treatment
Oral surgery
Major Services
Single crown restorations
Inlay/Onlay restorations
Labial veneer restorations
Crowns placed over implants
Periodontal scaling and maintenance
Full mouth debridement
Endodontic services
Surgical Periodontal services
Restorative and Prosthodontic services
Crown/bridge repairs
Adjustments
Recemenations
Orthodontics
Diagnostic procedures
Treatment
100% 100%
100% 100%
80% 80%
50% 50%
50% 50%
When the course of treatment will be in excess of $300, a predetermination request should be submitted to BCBSTX
in advance of treatment.
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VISION INSURANCE - HIGH PLAN
CARRIER: LINCOLN FINANCIAL
NETWORK: SPECTERA
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.myspectera.com.
● You must submit a claim form for out-of-network expenses.
● LASIK surgery discounts available
ELECTION
MONTHLY EMPLOYEE COST
Employee Only $9.33
Employee & Spouse $17.68
Employee & Child(ren) $20.75
Employee & Family $29.19
COVERED BENEFITS IN-NETWORK OUT-OF-NETWORK
Eye Exam (every 12 months) $10 copay Up to $40 reimbursement
Lenses (every 12 months)
Single: 100% after $10 copay
Bifocal: 100% after $10 copay
Trifocal: 100% after $10 copay
Lenticular: 100% after $10 copay
Single: $40 copay reimbursement
Bifocal: $60 copay reimbursement
Trifocal: $80 copay reimbursement
Lenticular: $80 copay reimbursement
Frames (every 12 months) Up to $130 allowance Up to $45 reimbursement
Contact Lenses (every 12 months)
Elective
Covered
Medically Necessary
Up to $125 allowance
100% after $10 copay
100% after $10 copay
Up to $125 reimbursement
Up to $125 reimbursement
Up to $210 reimbursement
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VISION INSURANCE - LOW PLAN
CARRIER: LINCOLN FINANCIAL
NETWORK: SPECTERA
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.myspectera.com.
● You must submit a claim form for out-of-network expenses.
● LASIK surgery discounts available
ELECTION
MONTHLY EMPLOYEE COST
Employee Only $8.67
Employee & Spouse $16.43
Employee & Child(ren) $19.27
Employee & Family $27.12
COVERED BENEFITS IN-NETWORK OUT-OF-NETWORK
Eye Exam (every 12 months) $10 copay Up to $40 reimbursement
Lenses (every 12 months)
Single: 100% after $10 copay
Bifocal: 100% after $10 copay
Trifocal: 100% after $10 copay
Lenticular: 100% after $10 copay
Single: $40 copay reimbursement
Bifocal: $60 copay reimbursement
Trifocal: $80 copay reimbursement
Lenticular: $80 copay reimbursement
Frames (every 24 months) Up to $130 allowance Up to $45 reimbursement
Contact Lenses (every 12 months)
Elective
Covered
Medically Necessary
Up to $125 allowance
100% after $10 copay
100% after $10 copay
Up to $125 reimbursement
Up to $125 reimbursement
Up to $125 reimbursement
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BASIC LIFE AND AD&D INSURANCE
CARRIER: LINCOLN FINANCIAL
This coverage is provided by City of Nacogdoches at no
cost to you.
Safeguard the most important people in your life.
Think about what your loved ones may face after you're gone. Term life insurance can help them in
so many ways, like covering everyday expenses, paying off debt, and protecting savings. AD&D
provides even more coverage if you die or suffer a covered loss in an accident.
AT A GLANCE:
● A cash benefit of $20,000 to your loved ones in the vent of your death, plus a
matching cash benefit if you die in an accident
● A cash benefit to you if you suffer a covered loss in an accident, such as losing a
limb or your eyesight
● LifeKeys services, which provide access to counseling, financial and legal support
● TravelConnect services, which give you and your family access to emergency
medical assistance when you’re on a trip 100+ miles from home
You also have the option to increase your cash benefit by securing additional coverage at affordable
group rates. See the enclosed life insurance information for details.
ADDITIONAL DETAILS
Conversion: You can convert your group term life coverage to an individual life insurance policy
without providing evidence of insurability if you lose coverage due to leaving your job or for
another reason outlines in the plan contract. AD&D benefits cannot be converted.
Continuation of Coverage: You may be able to continue coverage if you leave your job for any
reason other than sickness, injury, or retirement.
Benefit Reduction: Coverage amounts begin to reduce at age 65 and benefits terminate at
retirement. See the plan certificate for details.
For complete benefit descriptions, limitations and exclusions, refer to the certificate of coverage.
REMINDER
Review your beneficiary designations
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VOLUNTARY LIFE INSURANCE
CARRIER: LINCOLN FINANCIAL
Voluntary life insurance is offered through your employer but is paid in full by employees.
WHY PURCHASE VOLUNTARY LIFE INSURANCE?
● This type of life insurance has limited underwriting required. This allows for people with health
conditions or lifestyles that might otherwise disqualify them to qualify for life insurance.
● The group rates are lower than what you could purchase on your own.
● You may purchase a policy for your spouse and children IF you elect coverage for yourself.
Employee Coverage
Newly hired employee guaranteed coverage amount: $150,000
Continuing employee guaranteed coverage annual increase amount: Choice of $10,000 or $20,000
Maximum coverage amount: 5 times your annual salary, not to exceed $300,000
Minimum coverage amount: $10,000
AD&D coverage amount: Equal to the life insurance amount chosen
Spouse Coverage - you can secure term life insurance for your spouse if you select coverage for yourself.
Newly hired employee guaranteed coverage amount: $30,000
Continuing employee guaranteed coverage annual increase amount: Choice of $5,000 or $10,000
Maximum coverage amount: 50% of the employee coverage amount, not to exceed $150,000
Minimum coverage amount: $5,000
AD&D coverage amount: Equal to the life insurance amount chosen
Dependent Children Coverage - you can secure term life insurance for your dependent children under age 26
when you select coverage for yourself.
6 months to age 26 (if unmarried) guaranteed coverage amount: $20,000
Age 14 days to 6 months guaranteed coverage amount: $250
During open enrollment, an employee may choose to elect or increase his/her Voluntary Life and AD&D
amount by $10,000 or $20,000 without providing evidence of insurability. An employee may also choose to
elect or increase his/her spouse’s Voluntary Life and AD&D amount by $5,000 or $10,000 without providing
evidence of insurability. Any amount requested over the allowed 2 incremental amounts will require evidence
of insurability.
For those requiring evidence of insurability, please download from the Voluntary Life screen in Employee
Navigator, complete, and return to Human Resources no later than 8/20/2021.
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VOLUNTARY LIFE INSURANCE
CARRIER: LINCOLN FINANCIAL
25

LONG TERM DISABILITY INSURANCE
CARRIER: LINCOLN FINANCIAL
90 Day Waiting Period
Long-term disability (LTD) insurance will be calculated from your base rate of
pay (hourly rate) unless you choose to have your benefit calculated from your
prior year’s W2 earnings. Should you elect prior year W2 earnings, you MUST
contact the Human Resources department to request this change.
LTD insurance is designed to help you meet your financial needs during longer
disability periods. Benefit may be offset due to other benefits such as paid
sick leave, workers’ compensation.
• Benefits – 60% of your monthly salary limited to $5,000 per month
• Elimination Period: 90 days
• Maximum coverage period: Up to age 65 or SSNRA
• Pre-Existing Condition: If you have a medical condition that begins before
your coverage takes effect, and you recieve treatment for this condition
within the 3 months leading up to your coverage start date, you may not be
eligible for benefits for that condition until you have been covered by the
plan for 12 months.
REMINDER
Review your beneficiary designations
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LONG TERM DISABILITY INSURANCE
CARRIER: LINCOLN FINANCIAL
180 Day Waiting Period
Long-term disability (LTD) insurance will be calculated from your base rate of
pay (hourly rate) unless you choose to have your benefit calculated from your
prior year’s W2 earnings. Should you elect prior year W2 earnings, you MUST
contact the Human Resources department to request this change.
LTD insurance is designed to help you meet your financial needs during longer
disability periods. Benefit may be offset due to other benefits such as paid
sick leave, workers’ compensation.
• Benefits – 60% of your monthly salary limited to $5,000 per month
• Elimination Period: 180 days
• Maximum coverage period: Up to age 65 or SSNRA
• Pre-Existing Condition: If you have a medical condition that begins before
your coverage takes effect, and you recieve treatment for this condition
within the 3 months leading up to your coverage start date, you may not be
eligible for benefits for that condition until you have been covered by the
plan for 12 months.
EMINDER
eview your beneficiary designations
REMINDER
REMINDER
Review your beneficiary designations
Review your beneficiary designations
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EMPLOYEE ASSISTANCE PROGRAM
CARRIER: LINCOLN FINANCIAL
28 28

ENROLLMENT INSTRUCTION
The City of Nacogdoches is using a new and improved enrollment platform called Employee Navigator.
Each employee will need to login to review current elections and make elections for the new plan year.
Web address for online enrollment is https://employeenavigator.com/benefits/Account/Login
If you do not have a username, click “register as a new user”. You will be asked to enter your
First Name, last Name, Company Identifier of NACTX , Pin (last 4 of SSN) and Birth Date. You
will create a username and password, be sure to write this down and keep in a safe place for
future use.
Enter username & password and click Login. You will then be prompted to review your current
elections and make any changes for the elections effective 10/1/2021.
If you have previously logged in but do not remember your password, click “Reset a forgotten
password”. You will be prompted to enter your username and birth year to reset your
password.
If you do not log in and request any changes for the new plan year, your current elections WILL
automatically be rolled for the 2021/ 2022 plan year with exception of Flexible Spending Accounts.
You MUST login and re-elect that benefit each year.Please review the new plan year information
closely. After you have completed your enrollment, be sure to hit the “click to sign” button on your
Enrollment Summary page.
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REMINDERS
Employees are responsible for notifying Human Resources if a dependent is no longer eligible for
coverage. Failure to notify HR will affect COBRA availability and premium refunds.
From time to time additional information may be requested by the carriers as it relates to your
benefits- please respond promptly to expedite processing.
Questions & Answers
What steps MUST be taken to complete my Open Enrollment?
➢ Employees MUST go online to elect and/or decline benefits.
➢
Employees completing their enrollment online will have the option to choose Pre Tax or
Post Tax for benefits such as Medical, Dental and Vision.
When MUST my enrollment be completed?
➢
All benefit elections must be submitted online by August 20th.
Who do I contact with questions?
➢
Contact the Human Resources department at City of Nacogdoches at 936- 559-2567 or
Lacey Parmer with BXS Insurance at 936-564-1713 with any questions you may have.
DEADLINE FOR ONLINE ENROLLMENT AND
SUBMITTING ALL FORMS IS AUGUST 20th.
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IMPORTANT CONTACTS
BENEFIT CARRIER PHONE WEBSITE
Medical and Pharmacy (Prime Therapeutics) BlueCross BlueShield of Texas 1-800-521-2227 www.bcbstx.com
Flexible Spending Account TASC 1-800-422-4661 www.tasconline.com
Dental Insurance BlueCross BlueShield of Texas 1-800-422-2567 www.bcbstx.com
Vision Insurance Lincoln Financial 1-800-422-2567 www.lfg.com
Basic and Voluntary Life AD&D Insurance Lincoln Financial 1-800-422-2567 www.lfg.com
Long Term Disability Lincoln Financial 1-800-422-2567 www.lfg.com
Employee Assistance Program Lincoln Financial 1-800-422-2567 www.lfg.com
Human Resources 936-559-2567
YOUR BXS INSURANCE ACCOUNT REPRESENTATIVE:
Lacey Parmer
936-564-1713
Lacey.parmer@bxsi.com
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City of Nacogdoches
936.559.2567