Employee BENEFITS GUIDE for · 2019-05-09 · Life Insurance Plans 12 Employee Benefit Center 13...

Employee BENEFITS GUIDE for

Jan 1, 2017 - Dec 31, 2017

PLAN YEAR

BUTCH’S RAT HOLE & ANCHOR SERVICE

EMPLOYEE BENEFITS GUIDE

Welcome to your Butch’s Benefits Guide.

We take great pride in offering an excellent selection of benefits to all full-

time employees. This guide provides quick access to information about

your employee benefits program, which is an important part of your total

compensation package. Please take a few moments to familiarize yourself

with the benefit programs available to you as part of the Butch’s family.

Table of Contents

DISCLAIMER: The information provided in this booklet is for summary purposes only,

and is not a comprehensive explanation of benefits or legal document. Please refer to

the full Summary Plan Description provided by the insurance companies. In the event of

a discrepancy between the Summary Plan Description and this document, the carriers’

Summary Plan Description will prevail.

The benefits illustrated in this book are in-network benefits. Check your individual plan for

out-of-network benefits. If you use an out-of-network provider you may be balanced billed

for any charges that are greater than the allowable amount* defined by your network.

iaCONSULTING 2016. All Rights Reserved.

Eligibility & Enrollment Guidelines 3

Payroll Deduction Options 3

Medical Plans, Rates & Features 4

Telemedicine Services 8

Dental Plan 9

Vision Plan 10

Dental/Vision Plan Rates 11

Life Insurance Plans 12

Employee Benefit Center 13

Contacts 14

Notes 15

3

Eligibility & Enrollment Guidelines

Full-time employees of Butch’s are eligible to enroll in the benefit plans

on the first day of the month following 60 days of full-time employment.

Employees who do not elect coverage at this initial eligibility date will

only be able to enroll during the next open enrollment period, or if they

experience an applicable qualifying event.

Open enrollment is the one opportunity during the year when you may

make changes to your current benefit elections for both yourself and

any eligible dependents without having a qualifying event. Examples of

qualifying events include: marriage, divorce, birth or adoption of a child,

loss of a dependent, court order, loss of other coverage, or significant

change in employment status of you or your spouse. If you experience

one of these qualifying events, please contact Human Resources within

30 days of the event.

The benefit elections you make will be effective January 1, 2017 through December 31, 2017.

Payroll Deduction Options

As a participant of the medical plan, dental and/or vision plans, you will

have the option to pay for your portion of the plan premiums with pre-tax

deductions or with post-tax deductions.

Pre-Tax Election:

◗Allows member to pay for plan premiums with pre-tax payroll deductions. This may decrease the member’s overall tax liability.

◗Requires the member to maintain coverage during the entire plan year, not allowing changes or cancellations of coverage unless there is a qualified family change.

Post-Tax Election:

◗Requires member to pay for plan premiums with post-tax payroll deductions.

◗Allows the member to cancel coverage at any time. The member could not re-enroll until the next open enrollment.

IMPORTANT: Your deductions for this plan will be AUTOMATICALLY taken Pre-Tax unless you opt out in writing and submit to Human Resources prior to the start of coverage.

4

Medical Plans

The medical plans are offered through BlueCross and BlueShield of Texas.

You can elect from three medical plans: HSA, Base PPO and Buy Up PPO.

Below you will find a summary of benefits for all plans.

IN-NETWORK BENEFITS

HSA PLANBASE PPO

PLANBUY-UP

PPO PLANCOPAYS

Primary Care Physician 100% after Deductible $30 $30

Specialist 100% after Deductible $55 $55

Urgent Care 100% after Deductible $50 $50

PRESCRIPTION DRUGS

Prescription Deductible $0 $100 $0

Preferred Generic 100% after Deductible $10 $10

Preferred Brand Name 100% after Deductible $35 $35

Non-Preferred Brand Name

100% after Deductible $60 $60

Specialty 100% after Deductible 20% 20%

CALENDAR YEAR DEDUCTIBLE

Individual $6,550 $5,000 $3,000

Family $13,100 $10,000 $6,000

OUT OF POCKET LIMIT (INCLUDES DEDUCTIBLE)

Individual $6,550 $6,350 $6,000

Family $13,100 $12,700 $12,000

MEMBER COINSURANCE

Preventive Care Covered at 100%Covered at

100%Covered at

100%

Lab and X-ray 100% after DeductibleCovered at

100%Covered at

100%

Diagnostic Imaging (MRI, Pet Scans, CT Scans, etc.)

100% after Deductible $250 copay $250 copay

Hospital Services 100% after Deductible30% after

Deductible20% after

Deductible

Emergency Services 100% after Deductible$400 Copay,

then 30% after Deductible

$400 Copay, then 20% after

Deductible

5

Medical Plan Rates

BI-WEEKLY EMPLOYEE MEDICAL CONTRIBUTIONS

Payroll deductions take effect on first pay period after 01/01/2017

COVERAGE TIER HSA Base PPO Buy Up PPO

Employee Only $43.85 $53.54 $95.17Employee + Child/ren $159.93 $185.18 $262.15

Employee + Spouse $251.80 $285.92 $389.93Employee + Family $315.38 $355.64 $478.37

SEMI-MONTHLY EMPLOYEE MEDICAL CONTRIBUTIONS


COVERAGE TIER HSA Base PPO Buy Up PPO

Employee Only $47.50 $58.00 $103.10Employee + Child/ren $173.26 $200.61 $284.00

Employee + Spouse $272.78 $309.75 $422.42Employee + Family $341.66 $385.28 $518.23

Benefits Assistant

Butch’s employees have access to a dedicated Account Manager who will

help resolve any issues you may have with your benefit plans. Please call

Natalia Moore if you need assistance with the following:

• Benefit Coverage Questions

• Incorrect Claims Processing

• Locating In-Network Physicians and Hospitals

• Out-of-Network Negotiations & Balance Billing

• And More!

iaCONSULTING is here to help you!

Natalia Moore, Senior Account Manager

806.765.7264 or 866.765.7264 | [email protected]

6

Plan Features

HSA PLAN FEATURES

As a participant in Butch’s HSA-compatible High Deductible Health Plan,

you have the option to open a Health Savings Account (HSA) Bank Account

to pay for qualified medical expenses tax-free.

HSA-compatible plans do not have office visit or prescription copays. While

you do receive the BlueCross and BlueShield of Texas (BCBSTX) provider

discount, you are responsible for all medical costs up to the deductible

amount, after which the plan will pay at 100% for the remainder of the

plan year. The only exception is preventive care services (i.e. baby well-

checks, annual physical, annual women well-check, etc.) which the plan

always covers at 100%. The plan allows you access to both In-Network and

Out-of-Network providers, but utilizing In-Network maximizes the benefits

of the plan.

Find BCBSTX PPO Network providers by visiting www.bcbstx.com and

clicking “Find a Doctor,” selecting your state, then “BlueChoice PPO.”

You can also call 800-521-2227 for assistance!

You can make contributions directly to the HSA bank account and can

deduct the contributions (even if you do not itemize deductions) when

completing your federal income tax return. The IRS determines the

maximum amount that can be contributed to an HSA, and adjusts them

annually for inflation. For 2017, the maximum contribution for Self-Only

coverage is $3,400, and $6,750 for Family coverage. For individuals age 55

and older, the IRS permits an additional annual “catch-up” contribution

of $1,000.

You can use the money in the HSA bank account for any “qualified medical

expense” permitted under federal tax law. This includes most medical

care and services, dental and vision care. Any amounts used for purposes

other than to pay for “qualified medical expenses” are taxable as income

and subject to an additional tax penalty.

7

An HSA provides you triple tax savings: (1) contributions to your account

are tax-deductible; (2) tax-free earnings through investment; and, (3) tax-

free withdrawals for qualified medical expenses.

EMPLOYEES WHO ARE NOT ELIGIBLE TO OPEN A TAX-FREE ACCOUNT

• Those over 65 and have Medicare coverage

• Those who have received benefits from the VA in the 3 months prior

• Employees who are covered by another health plan that is NOT an

HSA-compatible High Deductible Health Plan

YOU RETAIN COMPLETE CONTROL OVER ALL ASPECTS OF THE

HSA BANK ACCOUNT, INCLUDING:

• how much money you put into the account

• whether to use the account for current or future medical expenses

• which medical expenses to pay from the account

• whether to invest any of the money in the account

• which investments to make

PORTABILITY

HSA Bank Accounts are completely portable, meaning you can keep your

HSA even if you change jobs, change your medical coverage, become

unemployed, move to another state, or change marital status. The funds

remain in the account from year to year and are not subject to a “use it or

lose it” rule.

PPO PLAN FEATURES

Preferred Provider Organization (PPO) plans provide In-Network and

Out-Of-Network benefits. The comprehensive PPO plans feature a lower

deductible and a traditional office visit and prescription copay structure.

To obtain the highest benefit level, always try to find In-Network providers.

Find PPO Network providers by visiting www.bcbstx.com and clicking

“Find a Doctor,” selecting your state, then “BlueChoice PPO.” You can

also call 800-521-2227 for assistance!

8

Telemedicine Services

091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT

PROVIDE MEDICAL HISTORY

Your medical history provides Teladoc doctors with the information they need to make an accurate diagnosis.

Downloadthe app:Facebook.com/Teladoc Teladoc.com/mobile

Talk to a doctor anytime for Free

© 2016 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. © 2016 Teladoc, Inc. Todos los derechos reservados. Teladoc y el logotipo de Teladoc son marcas de Teladoc, Inc. y no pueden ser utilizados sin permiso por escrito. Teladoc no sustituye al médico de atención primaria. Teladoc no garantiza que una receta se escribe. Teladoc opera sujeta a la regulación estatal y pueden no estar disponibles en ciertos estados. Teladoc no prescribir sustancias controladas DEA, las drogas no terapéuticas y algunos otros medicamentos que pueden ser perjudiciales debido a su potencial de abuso. Médicos Teladoc reservamos el derecho de negar la atención por el mal uso potencial de los servicios.

Teladoc.com 1-800-Teladoc (835-2362)

It's quick and easy online. Visit the Teladoc website at Teladoc.com, click "Set up account" and provide the required information. You can also call Teladoc for assistance over the phone.

Once your account is set up, request a consult anytime you need care.

Online: Log into Teladoc.com and click "My Medical History". Mobile app: Log into your account and complete the "My Health Record" section. Visit Teladoc.com/mobile to download the app. Call Teladoc: Teladoc can help you complete your medical history over the phone.

Teladoc's U.S. board-certif ed doctors are available 24/7/365i to resolve many of your medical issues through phone or video consults. Set up your account today so when you need care now, a Teladoc doctor is just a call or click away.

Getting started with Teladoc®

Get started with Teladoc!

Medical plan participants and their dependents can start using the telemedicine services. You can set up your account online, on the mobile app or by phone. Remember, your consult fee is $0!

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REQUEST A CONSULT














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REQUEST A CONSULT














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REQUEST A CONSULT














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REQUEST A CONSULT














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REQUEST A CONSULT














9

091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














Dental Plan

Butch’s provides all full-time employees with a dental insurance plan

administered by Ameritas. Employees may elect to purchase coverage for

themselves and their dependents.

Ameritas’ Dental Rewards Program allows $250 of unused maximum

benefit to carry over to the next year, for up to four times the carry over

amount if:

◗You have at least one dental service performed within the calendar year

◗You accrued less than $750 in total claims within the calendar year

Below is a summary of benefits under the plan.

PLAN BENEFITS

Calendar Year Deductible Individual $50

Preventive Care (e.g. Cleanings)

100%, Deductible Waived

Basic Care (e.g. Fillings) 80%, After Deductible

Major Care (e.g. Crowns, Dentures)

50%, After Deductible

Orthodontia (Child Only Up To Age 19)

50%, After Deductible (12 Month Waiting Period)

Annual Maximum Benefit $2,000 Per Covered Person

Orthodontia Lifetime Max $1,000 Per Covered Person

The dental policy covers two routine cleanings per year

at NO COST to you when visiting in-network providers.

10

Vision Plan

Butch’s also provides a vision insurance plan to all employees and their

dependents through Ameritas, utilizing the VSP network of providers.

Employees may elect to purchase coverage for their dependents.

IN-NETWORK OUT-OF-NETWORKANNUAL DEDUCTIBLES

Eye Exam Deductible $10 $10

Materials Deductible $25 $25

EYE EXAM COVERED AT 100% UP TO $45 ALLOWANCE

LENSES

Single Vision Covered at 100% Up to $30 allowance

Bifocal Covered at 100% Up to $50 allowance

Trifocal Covered at 100% Up to $65 allowance

Lenticular Covered at 100% Up to $100 allowance

Progressive See lens options N/A

FRAMES UP TO $130 ALLOWANCE UP TO $70 ALLOWANCE

CONTACT LENSES (IN LIEU OF GLASSES)

Exam and fitting 15% discount N/A

Elective Contacts Up to $130 allowance Up to $105 Allowance

FREQUENCIES

Exams Once every 12 months Once every 12 months

Lenses Once every 12 months Once every 12 months

Frames Once every 24 months Once every 24 months

Contacts Once every 12 months Once every 12 months

11

Dental/Vision Plan Rates

DENTAL/VISION PLAN PAYROLL DEDUCTIONS


Coverage Tier Bi-Weekly Semi-Monthly

Employee Only $0.00 $0.00

Employee + Spouse $15.81 $17.12

Employee + Children $19.76 $21.40

Employee + Family $35.37 $38.32

You may choose any dentist. However, if you elect to see an out-of-

network provider, you may be balance billed for anything over the usual,

reasonable and customary amount allowed by Ameritas. You can locate

in-network dentists at www.ameritas.com, or by calling 1.800.487.5553.

Locate an in network Vision provider at www.VSP.com or call 1.800.877.7195.

If you use an out-of-network provider the benefits will be reduced and you

will be required to submit a reimbursement to Ameritas along with the

receipt for your related expenses.

12

LIFE INSURANCE PLANS

BASIC TERM LIFE AND AD&D

Butch’s provides employees with Basic Term Life and Accidental Death &

Dismemberment coverage through Unum. This coverage is provided for

all active full-time employees at no cost!

BASIC LIFE AND AD&D BENEFITS

Life Benefit $50,000

AD&D Benefit $50,000

Age Reduction Schedule35% at age 65, 50% at age 70,

VOLUNTARY TERM LIFE

Butch’s also offers all active full-time employees the option to purchase Term Life Insurance coverage through Unum. This coverage would be in addition to the Basic Group Life coverage.

VOLUNTARY TERM LIFE BENEFITS GUARANTEE ISSUE*

Employee Benefit

In $10,000 increments, up to $500,000 or 5x annual earnings, whichever is less.

$150,000

Spouse BenefitUp to 100% of employee’s coverage in increments of $5,000, not to exceed $500,000

$25,000

Child BenefitUp to 100% of employee’s coverage in increments of $2,000, not to exceed $10,000

$10,000

Voluntary Term Life premium rates are based on age and coverage amounts. See Plan Document for rate table. *Guarantee Issue amounts are only available at initial eligibility.

Please be sure you have a current designation of beneficiary form on file!

13

The Butch’s Employee Benefits Center (EBC) provides employees and

their families with online access to your detailed benefit information 24/7.

EMPLOYEE BENEFIT CENTER

Go to: www.mybutchsbenefits.com

14

CONTACTS

BUTCH’S RAT HOLE &

ANCHOR SERVICE

HR Department

Eddie Wilson

[email protected]

Lisa Vargas

[email protected]

806.894.6294

MEDICAL BENEFITS

BlueCross and BlueShield of Texas

1.800.521.2227

www.bcbstx.com

DENTAL BENEFITS

Ameritas Group

1.800.487.5553

www.ameritas.com

iaCONSULTING

Natalia Moore, SeniorAccount

Manager

[email protected]

1.806.765.7264

866.765.7264 (toll free)

VISION BENEFITSAmeritas Group/VSP

1.800.877.7195

www.vsp.com

LIFE BENEFITS

Unum Life Insurance

877.225.2712

www.unum.com

15

NOTES

700 Austin Street

Levelland, TX 79336

806-894-6294

Employee BENEFITS GUIDE for · 2019-05-09 · Life Insurance Plans 12 Employee Benefit Center 13...

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