Explanation
of Medical Benefits
Great-West
Life & Annuity Insurance Company, Provider
NewData
Strategies believes in giving our employees a choice,
therefore we offer two types of medical coverage:
HMO, One Health Plan - A managed care program. To
receive benefits, health care needs to be coordinated
through your selected Primary Care Physician (PCP).
Non-emergency care received outside the service area
will not be covered. Service areas includes Dallas
and Houston and their surrounding counties.
-or-
PPO, Preferred
Provider Organization - A nationwide network of doctors,
hospitals and other health care providers. You may
go to any doctor or hospital each time you need care.
However to obtain the high level of benefits, network
providers should be utilized. The Plan is subject
to special limitations for Preexisting Conditions,
pregnancy excluded.
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Additional
Medical Benefits Include
- Prescription Card (HMO Network
or PPO (PCS) Network)
- Dental Coverage (non-network)
- Vision Coverage (non-network)
- Flexible Benefit Account
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Eligibility
for Coverage
To be eligible for coverage
for yourself and your Dependents for the above plans
you must:
- Be a full-time Employee
who regularly works at least 32.00 hours each week
- Complete 30 days of continuous
Service with NewData Strategies
- Be a resident of the United
States
- Dependent - legal spouse
- Dependent - unmarried child
under the age of 19
- Dependent - unmarried child
under the age of 23 and classified as a full-time
student (PPO Only)
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Late
Applicant
A person (you
or your Dependent) will be considered a late applicant
under either Plan if:
- You have to make a contribution
and don't apply for coverage within 31 days of the
date you become eligible to cover that person; or
- You do not have to make
a contribution but elect not to cover that person;
and you later want coverage for that person.
- Late applicants can apply
for PPO coverage subject to "Proof of Good
Health"
- Late applicants can apply
for HMO coverage during the Open Enrollment Period.
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Exceptions
to the Definition of Late Applicant - Special Enrollee
(PPO Only)
For Medical, Prescription
Drug, Dental and Vision coverage under this Plan a
person (you or your Dependent) will not be considered
a late applicant if:
- You waived coverage for the person within 31 days
of the date you became eligible to do so because
the person was covered under another health insurance
plan or arrangement (other plan); and coverage under
the other plan was lost as a result of:
- Exhausting the maximum period
of COBRA coverage; or
- Loss of eligibility for the other
plan's coverage due to legal separation, divorce
or death of a spouse; or
- Termination of employment or
reduction in the number of ours of employment;
or
- Termination of the employer's
contribution for the other plan's coverage.
- You did not apply to cover
your spouse or a Dependent child within 31 days
you became eligible to do so and later are required
by a court order to provide coverage for that person.
- You did not apply to cover yourself or an eligible
Dependent within 31 days of the date you became
eligible to do so and later experience a change
in family status because you acquire a Dependent
through marriage birth or adoption. In this case,
you may apply to cover yourself and any of your
eligible Dependents.
Request for PPO insurance enrollment must be made
within 31 days following the lost of coverage or 31
days after acquiring coverage as described above.
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Modification/Termination
of Coverage
NewData Strategies
intends to provide benefits under the various medical
plans indefinitely. However, as the Employer, we may
at any time:
- Change the contributions
you must pay for benefits; or
- Amend or terminate the benefits
provided to you in the Plans
- For Medical (PPO or HMO),
Prescription Drug, Dental, Vision Benefits and Flexible
Benefit Account, coverage ends on the date your
active full-time service ends for any reason.
To verify that your selected
physician is currently active in the HMO or PPO Network,
contact the appropriate office from the list below:
- HMO 1-800-685-3620
- PPO 1-800-685-3020
- POLICY NO. 263221
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Medical
Benefit Highlights
|
Within
Network
|
HMO
|
PPO
|
|
Deductible
|
None
|
None
|
|
Office
Visits
|
100%
after $10 copay
|
100%
after $10 copay
|
|
Emergency
Room Visits
|
100%
after $50 copay
|
100%
after $50 copay
|
|
Outpatient
Surgery
|
100%,
no copay
|
100%,
$100 copay
|
|
Hospital
Treatment (Inpatient)
|
100%,
no copay
|
100%,
$100 copay
(Copay first 5 days confinement)
|
|
Outpatient
Mental Health Trtmnt.
|
100%
after $25 copay
(20 visits per cal. yr.)
|
100%
after $25 copay
(20 visits per cal. yr.)
|
|
Annual
Out-of-pocket Maximum (Family)
|
$1,000
(3x)
|
$1,500
(3x)
|
|
Services
Outside PPO Network or for which no PPO Providers
are available:
| Deductible
(Family) |
$250.00
(3x)
|
| Office
Visits |
100%
after $10 copay
|
| Hospital
Deductible |
$250
per confinement or outpatient surgery
|
| Coinsurance |
80%
|
| Breakpoint
(Family) |
$7,500
(3x)
|
|
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Services
provided by a Non-Network PPO Provider in a Great-West
Geographical area:
|
Deductible
(Family)
|
$250(3x)
|
|
Hospital
Deductible
|
$250
per confinement or outpatient surgery
|
|
Coinsurance
|
70%
|
|
Breakpoint
(Family)
|
$7,500
(3x)
|
|
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Services
provided by a Non-Network HMO Provider:
|
Deductible
(Family)
|
$500(3x)
|
|
Hospital
Deductible
|
$250
per confinement or Outpatient surgery
|
|
Coinsurance
|
50%
|
|
Annual
Out-of-pocket Mxm
|
$10,000
(3x)
|
|
Summary
of Prescription Drug Benefits
| Network
Pharmacy: |
|
|
HMO
|
PPO
|
|
Generic
Drugs
|
100%
after $5 copay |
100%
after $5 copay |
|
All
Other Drugs
|
100%
after $10 copay |
100%
after $10 copay |
| Non-Network
Pharmacy: |
|
|
HMO
|
PPO
|
|
Generic
Drugs
|
50%
after $5 copay |
50%
after $5 copay |
|
All
Other Drugs
|
50%
after $10 copay |
50%
after $10 copay |
|
Mail Service Prescription Drugs: |
|
|
HMO
|
PPO
|
|
Percentage
Payable
|
100%
after $10 copay |
100%
after $10 copay |
|
Summary
of Dental Coverage
Dental benefits
are payable only if you or your dependents are provided
services by a licensed Dentist, a licensed Doctor
and/or a Dental Assistant or a Dental Hygienist working
under the direct supervision of a Dentist.
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Late
Applicants (Dental)
A person (you
or your dependents) will be considered a late applicant
if the coverage starts more than 31 days after he
or she first becomes eligible. For late applicants,
no benefits are payable for:
- Basic and Major
treatment received within 12 months of the date
coverage starts; and
- Orthodontic
treatment received within 24 months of the date
coverage starts.
However, benefits
will be payable if the treatment is needed because of
an accidental injury to natural teeth that occurs after
the date coverage
starts. Chewing injuries are not considered accidental
injuries.
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Services
Provided (Dental)
| Deductible |
(Family)
$50 (3x)
|
| Preventive
Treatment |
100%
(no deductible)
|
| Basic
Treatment |
80%
|
|
Major
Treatment* |
50%
|
|
Calendar
Year Maximum** |
$1,500
|
| Orthodontia
Treatment |
50%
|
|
Orthodontia
Lifetime Maximum*** |
$1,000
|
*Late applicants will not be eligible
for the first 12 months including
applicants added during the open
enrollment periods.
**For first year of employment
with a hire date of July 1 or
later the maximum benefit is $750.
***Dependent
children between ages 6 yrs
to 18 yrs
|
|
|
Summary
of Vision Coverage
Visions benefits
are payable only if a person (you or your dependents)
are provided services or supplies prescribed by a
licensed Ophthalmologist, a licensed Optometrist or
a qualified dispensing Optician.
Services Provided
(Per 24-month period)
| Deductible |
None
|
| Eye
Examinations |
100%
Maximum $45
|
| Eyeglass
lenses and frames/Contacts |
100%
Maximum $80
|
|
Flexible
Benefit Account
Enrollment Form (PDF Format: download Acrobat
Reader here)
Flexible Benefit
Account (FBA) is a valuable benefit that offers you
the opportunity to save tax dollars. Through an FBA,
your contributions to a health plan can be made on
a pretax basis. Then, you are given the opportunity
to pay certain other expected (potentially major)
expenses on a pretax basis, including non-covered
health care and dependent care expenses. Following
are the 3 ways to save with an FBA:
- Pretax Premium Deduction
- Premium contributions to your health plan are
deducted from your paycheck before taxes are calculated,
resulting in lower taxable income.
- Health Care Account - Set
aside pretax dollars to pay for expected out-of-pocket
medical, dental, vision and prescription drug expenses.
This includes deductibles, coinsurance payments,
co-payments and certain medical expenses not covered
by the health plan.
- Dependent Care Account -
If you are single or married and filing jointly,
you may set aside as much as $5,000 of your pretax
income for eligible dependent care expenses each
year. If you are married and filing separately,
you may set aside up to $2,500. You and your spouse
must each earn more than the amount you set aside.
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IRS Regulations (FBA)
Flexible Benefits
Accounts are made possible by Section 125 of the Internal
Revenue Code. Therefore, important federal tax rules
must be considered before enrolling.
- Prior to the beginning of
each plan year, you must indicate how much you wish
to contribute to each type of account during that
year. Money set aside for health expenses cannot
be used for dependent care or vice versa.
- You may change your annual
contributions only if you experience a change in
family status, such as marriage, divorce, or the
addition or loss of a dependent.
- At the end of the plan year,
you will forfeit any unspent funds remaining in
each account.
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