Aspen Heights 2018 Benefits Book

2018 Edition

EVERYTHING YOU NEED TO KNOW

INDEX (Click any topic to skip to that page) Pricing & Benefits Summary ............................................................................................................................... 1 Welcome to 2018 Open Enrollment ................................................................................................................ 3 How to Complete Open Enrollment ................................................................................................................ 5 Health Benefit Comparison Tool ..................................................................................................................... 15 BCBSTX – High Deductible Health Plan ..................................................................................................... 26 BCBSTX – Traditional Co-Pay Medical ........................................................................................................ 34 First Stop Health – Telemedicine Service ................................................................................................... 42 MetLife Dental Plan 1 (In Network) ................................................................................................................ 45 MetLife Dental Plan 2 (Out of Network)....................................................................................................... 52 MetLife Vision Summary ................................................................................................................................... 59 Liberty Mutual Short Term Disability............................................................................................................. 61 Liberty Mutual Long Term Disability ............................................................................................................ 62 Liberty Mutual Life and AD&D......................................................................................................................... 64 Liberty Mutual Employee Assistance Program ......................................................................................... 66 Liberty Mutual Additional Services ............................................................................................................... 68 Tango Health Savings Account ...................................................................................................................... 69 401K Plan ................................................................................................................................................................ 72 401K Rollover ...................................................................................................................................................... 102 401K Mobile App ................................................................................................................................................ 104 401K Participation Fee Disclosure ............................................................................................................... 106 ADP Employee Assistance Program (EAP) ............................................................................................... 126 Medicare Part D – Annual Notices .............................................................................................................. 130 Low In Network Dental Certificate............................................................................................................... 142 High Out of Network Dental Certificate..................................................................................................... 218 MetLife Vision Certificate ............................................................................................................................... 295 2018 Open Enrollment Meeting Deck ........................................................................................................ 358

Employee Health & Welfare Benefits Plan Year: 01/01/2018 – 12/31/2018 Aspen Heights provides an extensive benefits package to help you and your covered dependents. Following is a general summary of the benefits, including contact information and where you can find additional information. Full-time employees are eligible for benefits on the first of the month following date of hire.

Blue Cross Blue Shield of Texas (Group # 111459) Network Deductible

Individual Family

Coinsurance Out-of-Pocket (OOP) Maximum Surgery Office Visits

Individual Family

Primary Care Specialist Preventive Care Urgent Care Emergency Room Pharmacy Copays (Retail) Pharmacy Copays (Mail Order)

Traditional Co-Pay Plan (PPO MM09) Blue Choice $1,000 $3,000 80% $4,000 ($1,000 Rx) $10,200 ($3,000 Rx) 80% after deductible $25 Copay $25 Copay $0 Copay $50 Copay 80% after $100 Copay $20 / $35 / $50 $60/ $105 / $150

High Deductible Health Plan (HDHP MMH3) Blue Choice $5,000 $10,000 100% $5,000 $10,000 100% after deductible 100% after deductible 100% after deductible 100% (no deductible) 100% after deductible 100% after deductible 100% after deductible 100% after deductible

Telemedicine- First Stop Health Eligibility Consult Fee 24/7 Contact Phone Number

All medical plan participants No Cost to Access 888-691-7867

Account-Based Plans

Health Savings Account (HSA) 2018 Annual Maximum2 Company Annual Contribution Employee Only $3,450 $1,000 Employee + Spouse1 $6,900 $1,500 Employee + Child(ren) $6,900 $1,500 Employee + Family $6,900 $2,000 Requires enrollment in High Deductible Health Plan (HDHP MMH3) 1Please see IRS guidelines regarding HSA distributions for domestic partners 2Employees age 55 and older are allowed and optional $1,000 additional annual contribution.

ADP Flexible Spending Account (FSA) Medical Dependent Care (usually paired with Traditional Co-Pay Plan) $2,650 Annual Contribution Maximum $5,000 Annual Contribution Maximum MetLife (Group # 5932994) Dental Network

Network Deductible

Individual Family Coinsurance Levels by Preventive Care Service Type Basic Care Major Care Orthodontia Care Maximum Benefit Annual Orthodontia Lifetime Out-of-Network Reimbursement

Dental Plans MetLife PDP Plus Dental Plan 1 Best if using In-Network Providers $50 $150 100% (deductible waived) 100% after deductible 60% after deductible 50% (Adult & Child) $1,750 $1,500 Negotiated Fee

Dental Plan 2 Best if using Out-of-Network Providers $50 $150 100% (deductible waived) 80% after deductible 50% after deductible 50% (Adult & Child) $1,750 $1,500 90th R&C

MetLife (Group # 5932994) Vision Plan Vision Network VSP Network Copays Exam $10 copay Materials $25 copay Frequency Exam 12 Months Lenses 12 Months / 100% Contact Lenses* 12 Months / 100% (medically necessary) / $130 (elective) Frames 24 Months / Covered up to $130 allowance, then 20% discount off balance *Contacts are in lieu of glasses All health benefits (medical, dental and vision) offer out-of-network benefits. However, as a participant you will incur significantly greater costs because of increased deductibles and out-of-pocket maximums, decreased allowances and/or balance billing. Please confirm your doctor or physician is a network provider before receiving services in order to maximize your benefit.

Please note that this summary 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 summary and the legal plan documents, the plan documents are the final authority.

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Employee Health & Welfare Benefits Plan Year: 01/01/2018 – 12/31/2018 Liberty Mutual (Group # 09-468053) Benefit Maximum Benefit Guarantee Issue Liberty Mutual (Group # 09-468053) Benefit

Basic Life AD&D Plan 1x Salary to $50,000 $50,000 $50,000

Employee Units of $10,000 up to the lesser of 5x salary or $500,000 maximum $150,000

Guarantee Issue Evidence of Insurability

Voluntary Life AD&D Plan Spouse Units of $5,000 up to $250,000, not to exceed 50% of employee’s election $50,000

Child $5,000 or $10,000 if under 26 years of age N/A

Health Statement May Be Required

Liberty Mutual (Group # 09-468053) Coverage Amount Maximum Benefit Maximum Duration Benefits Begin Pre-Existing Condition Evidence of Insurability

Short Term Disability 60% of Weekly Earnings $2,000 Per Week End of 13th Week of Disability Day 15 of Injury or Sickness N/A N/A

N/A Voluntary Long Term Disability Plan 60% of Monthly Earnings $7,500 Per Month SSNRA Day 91 of Disability 12 / 12 Health Statement May Be Required

Deductions Per Paycheck (Semi-Monthly) Medical

Employee Only Employee + Spouse / Domestic Partner Employee + Child(ren) Employee + Family

Dental (Plan 1 & Plan2) High Deductible Health Plan (HDHP MMH3) $20.00 $5.45 $37.50 $15.81 $27.50 $16.35 $50.00 $27.25 Basic Life AD&D Plan 100% Employer Paid Voluntary Life AD&D Plan Please see rate sheet on ThinkAspen’s Talent page in the 2018 Benefits folder Short Term Disability 100% Employer Paid Voluntary Long Term Disability Please see rate sheet on ThinkAspen’s Talent page in the 2018 Benefits folder Traditional Co-Pay Plan (PPO MM09) $110.00 $258.33 $202.80 $357.15

Vision $1.00 $3.00 $3.00 $5.50

Liberty Mutual Employee Assistance Program (EAP) Liberty Mutual’s Employee Assistance Program (EAP) is accessible to help with the everyday challenges of life. 5 face-to-face sessions available.

Liberty Mutual Life Services Website Liberty Mutual’s Life Services Website is full of valuable information on legal and financial planning, online will preparation, wellness, grief and loss and more!

Carrier/Vendor Blue Cross Blue Shield of Texas MetLife Liberty Mutual Liberty Mutual

Benefit Covered Medical Dental & Vision Life, Voluntary Life, STD, LTD Life Services Website

Tango / Optum ADP / WageWorks ADP / LifeCare Liberty Mutual

HSA Administration / HSA FSA Employee Assistance Program Employee Assistance Program

Website www.bcbstx.com www.metlife.com/mybenefits www.mylibertyconnection.com www.BDAlifeservices.com Username: MLLIFE http://hsa.tangohealth.com www.spendingaccounts.info http://member.lifecare.com www.bensingerdupont.com/MLA Password: MLASSIST

Customer Service (800) 521-2227 (800) 275-4638 (888) 787-2129 N/A (866) 384-8549 (800) 228-5762 (800) 697-7315 (877) MYLBRTY

For additional support or questions regarding your health and welfare benefits, please contact: 84

(855) 889-3713 support@clspartners.com Monday – Thursday 8:00 am – 5:30 pm CST / Friday 8:00 am – 5:00 pm CST Watch our 2018 Open Enrollment Webinar at https://www.youtube.com/watch?v=1lMAR80iFCU&feature=em-share_video_user Please note that this summary 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 summary and the legal plan documents, the plan documents are the final authority.

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Welcome to Aspen Heights’ Annual Benefits Enrollment Period. This will be your only opportunity to make additions or changes to your benefits for 2018 so let’s make it count! You will have from November 1st-November 15th to select the elections going into effect on January 1st, 2018.

Wait a minute.. It’s enrollment time but what I am I supposed to be doing?

Well, fellow Aspenite, this is your chance to:  Add, change, or opt out of health plan, dental, and vision coverage  Enroll in your new Liberty Mutual plans (Voluntary Life Insurance and AD&D and Long Term Disability Coverage)  Enroll eligible family members in your plans  Enroll or re-enroll in a flexible spending account to pay for day care or health expenses with pretax dollars Already like what you have? Here’s what’s rolling over if you chose not to change it:  Blue Cross Blue Shield Medical plans (Traditional Co-Pay and High Deductible Health Plans)  MetLife Dental (In Network and Out of Network Plans)  MetLife Vision  Health Savings Account (HSA) deductions active on the last pay period of the year for HDHP members (set these through Tango) Here’s the ch-ch-changes (as David Bowie would say) NOTE: This means you must enroll if you want them!  Voluntary Life & AD&D  Voluntary Long Term Disability (LTD)  Flexible Spending Account (FSA) for Dependent Care  Flexible Spending Account (FSA) for Medical (only if you are enrolled in the Traditional Co-Pay Medical plan – contact Sarah Weiner in HR to set this up outside ADP) Aspen Heights [Hearts] You! Did you know that Aspen is paying for 100% of the following benefits?  Basic Life and Basic AD&D Insurance (at the value of your annual salary, up to $50,000)  NEW: Short Term Disability (STD)

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 

NEW: No Co-Pay Teledoc services through First Stop Health (must be enrolled in an Aspen Heights Health Plan) NEW: Blue Cross Blue Shield Wellness program (must be enrolled in an Aspen Heights Health Plan)

Need more information?

Go to ThinkAspen’s Talent tab and click on the 2018 Benefits folder and watch the recorded 2018 Open Enrollment webinar at https://www.youtube.com/watch?v=1lMAR80iFCU&feature=emshare_video_user.

For help, contact: Call ADP benefits support and technical assistance team @ 855-205-0566 for all of the below:  ADP Login/Locked out/Password Resets  Adding/Removing/Changing Dependents and Beneficiaries  Technical assistance with selecting/enrolling in plans  Technical assistance with dropping or changing a plan  Technical assistance with waiving the offered benefits  Technical assistance with confirming that your selections have been submitted Call CLS Partners’ fabulous benefit support team at 855-889-3713 or Support@CLSPartners.com (Mon.Thurs. 8:00am - 5:30pm CST, Fri. 8:00am - 5:00pm CST) for:  Questions about coverage  Questions about pricing  Questions about plan comparison If you have any other questions or deep thoughts on interesting topics, come find Sarah Weiner in the HR Office or call/email.

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid This job aid explains what you need to do to complete your 2018 benefit enrollments. The open enrollment period will be open from November 1st – November 15th, 2017. All changes to your benefits must be completed by November 15th at 6 PM CST. The changes that you make to your benefits will take effect on January 1, 2018.

Login to Our Portal Access ADP Workforce Now® here. (https://workforcenow.adp.com) Note: If this is your first time logging in select the link and follow the instructions in the email with the subject line “Welcome to Aspen Heights – ADP Access & Instructions”.

Enter your User ID and Password and click Login. To retrieve a lost User ID or Password, click the Forgot Your User ID/Password link for assistance. Note: Information or activity notification pages may display. Please respond as needed to continue.

How to Print Your Current Benefits List Before Starting Open Enrollment You don’t have to do this, but if you’d like to print a list of what you enrolled in for 2017, go to Myself > Benefits > Enrollments.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource. is a service mark of ADP, LLC. Copyright © 2016 ADP, LLC.

adp.com

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid In the top right section of the page, click on

, then scroll down to the bottom of the

screen and click . If you do this, you’ll need to go back through the menu (MYSELF > Benefits > Enrollments) to start your enrollment or log out of ADP and back in again and follow the directions below.

Open Enrollment Selections You may begin the open enrollment by selecting

on the Open Enrollment Splash Window.

Or from the menu select MYSELF > Benefits > Enrollments.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright © 2016 ADP, LLC.

adp.com

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid

On the Enrollments page, click Start or Resume next to your Open Enrollment profile.

(Resume is available when you are returning to complete your enrollment).

TIP: The Help page):

icon and the Full Screen



Click the Help



Click the Full Screen



Click the Restore

icon display on the top of the page (following the name of the

icon to find additional assistance and information. icon to expand the page you are viewing icon to return to the normal view.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright © 2016 ADP, LLC.

adp.com

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid 1. Review Dependents and Beneficiaries You may add a new dependent or beneficiary by selecting the drop down button and selecting the type from the dropdown list. Or to view a current dependent or beneficiary simply select their name from the list.

Complete the Dependent/Beneficiary information screen and click 2. Select your enrollment Status We recommend that you choose Walk Me Through My Benefit Options on the enrollment screen then click

Select a benefit plan from the list on the left. Tip: You may go through the plan categories in the order presented either by clicking a plan name on the left (going from top to bottom) or by using the move to the next plan category.

option to

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright Š 2016 ADP, LLC.

adp.com

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid

If you are already enrolled in a plan, it will show you as “Already Enrolled.” You have the option to Unenroll from that Plan, Edit the Plan, or Enroll in the other available Plan. To enroll in a plan, click appropriate benefit plan. For more information about the plan, click

for the , if this option is available.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright © 2016 ADP, LLC.

adp.com

ASPEN 2018 BENEFITS :: 9

Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid

Choose a Coverage Level for the selected plan, check the “enroll” box for your dependents if applicable. Then click

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright © 2016 ADP, LLC.

adp.com

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid

If you don’t make any changes, the below plans will roll over to 2018 at the new 2018 pricing.

• Blue Cross Blue Shield Medical plans (Traditional Co-Pay and High Deductible Health Plans) • MetLife Dental (In Network and Out of Network Plans) • MetLife Vision You MUST enroll in these plans if you want them for 2018 – they WILL NOT roll over automatically.

• Voluntary Life & AD&D • Voluntary Long Term Disability (LTD) • Flexible Spending Account (FSA) for Dependent Care • Flexible Spending Account (FSA) for Medical (only if you are enrolled in the Traditional Co-Pay Medical plan – contact Sarah Weiner in HR to set this up outside ADP)

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright © 2016 ADP, LLC.

adp.com

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid

Aspen Heights pays 100% of the following benefits for you (these are NOT in the Enrollment Wizard in ADP): • Basic Life and Basic AD&D Insurance (at the value of your annual salary, up to $50,000) • NEW: Short Term Disability (STD) • NEW: No Co-Pay Teledoc services through First Stop Health (must be enrolled in an Aspen Heights Health Plan) • NEW: Blue Cross Blue Shield Wellness program (must be enrolled in an Aspen Heights Health Plan)

After reviewing all plans and making your elections click . Note: You cannot select Review & Compete until all plans have been reviewed (until you have clicked on all of the plans on the left hand side of the screen). Once you have reviewed a plan (clicked on it), you’ll see a green check mark next to that plan.

If you need to leave the enrollment tool and return later to complete your election simply click . In the last step you will have the opportunity to review your benefit elections and provide a waive reason for any plan(s) you waived coverage. After the final review simply click

to submit your enrollment.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright © 2016 ADP, LLC.

adp.com

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Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid

If you need to leave the enrollment tool and return later to complete your election simply click . In the last step you will have the opportunity to review your benefit elections and provide a waive reason for any plan(s) you waived coverage.

One the Review and Complete screen, scroll down to #2 and select your reasons for waiving offered benefits.

After the final review simply click

to submit your enrollment.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright Š 2016 ADP, LLC.

adp.com

ASPEN 2018 BENEFITS :: 13

Employee Self Service Aspen Heights 2018 Annual Enrollment Job Aid Need to Make Changes?

If you need to make changes, you can do so through November 15th at 6 PM CST. Go to Myself > Benefits > Enrollments and click on RESUME or call ADP’s Benefits Service Center at 855-205-0566.

Need more information?

Go to ThinkAspen’s Talent tab and click on the 2018 Benefits folder and watch the recorded webinar at https://www.youtube.com/watch?v=1lMAR80iFCU&feature=em-share_video_user.

For help, contact: Call ADP benefits support and technical assistance team @ 855-205-0566 for all of the below: • ADP Login/Locked out/Password Resets • Adding/Removing/Changing Dependents and Beneficiaries • Technical assistance with selecting/enrolling in plans • Technical assistance with dropping or changing a plan • Technical assistance with waiving the offered benefits • Technical assistance with confirming that your selections have been submitted Call CLS Partners’ fabulous benefit support team at 855-889-3713 or Support@CLSPartners.com (Mon.-Thurs. 8:00am - 5:30pm CST, Fri. 8:00am - 5:00pm CST) for: • Questions about coverage • Questions about pricing • Questions about plan comparison

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource, is a service mark of ADP. LLC. Copyright © 2016 ADP, LLC.

adp.com

ASPEN 2018 BENEFITS :: 14

Plan Type

BCBS Medical - Traditional Co-Pay Employee Only (AKA BCBSTX PPO-MM09) Employee + Spouse Employee + Children Employee + Family

2018 Employee Premium Per Pay Period $ 110.00 $ 258.33 $ 202.80 $ 357.15

BCBS Medical - High Deductible Health Plan (HDHP) Employee Only (AKA BCBSTX HDHP-RMH3) Employee + Spouse Employee + Children Employee + Family

$ $ $ $

20.00 37.50 27.50 50.00

MetLife Dental Employee Only (both plans have the same premiums) Employee + Spouse Employee + Children Employee + Family

$ $ $ $

5.45 15.81 16.35 27.25

MetLife Vision Employee Only Employee + Spouse Employee + Children Employee + Family NOTE: 24 pay periods in a calendar/plan year

$ $ $ $

1.00 3.00 3.00 5.00

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2018

Plan Type

Employee Only Employee + Spouse Employee + Children Employee + Family

2018 Total IRS HSA Limit (Employee + Employer Contribution Limit) *

Aspen Heights Employer HSA Contribution (full year) ***

$ 3,450.00 $ 1,000.00 $ 6,900.00 $ 1,500.00 $ 6,900.00 $ 1,500.00 $ 6,900.00 $ 2,000.00 * Employees ages 55 or older can contribute an additiona ***AH Contributions split over the 24 pay periods, must

This table assumes you've been here for the full plan year Another way to come up with the amount you'd like to contribute to your HSA: Take the money you are saving on your per pay period insurance Premium cost and Health Savings Account through your payroll deduction TAX FREE! This way you wi account when you DO need to go to the doctor.

Plan Level Employee Only Employee + Spouse Employee + Children Employee + Family

2018 Traditional Co Pay Premium Per Pay Period $ 110.00 $ 202.80 $ 258.33 $ 357.15

High Deductible Premium Per Pay Period $ 20.00 $ 27.50 $ 37.50 $ 50.00

aditional Co-Pay Plan

High Deductible Health Plan

2018 Rates: WORST CASE, MAJOR HEALTH EVENT SCENARIO HDHP Deductible &Out of Pocket, In Network Max (spending above this amount is usually paid for by the plan at 100%) Plan Type Employee Only $ 5,000.00 Employee + Spouse (no $ 10,000.00 Employee + Children $ 10,000.00 Employee + Family $ 10,000.00 VS

Minus the last $2000 in out of pocket spending to hit the HDHP Deductible is reimbursable by Aspen Heights $ (2,000.00) $ (2,000.00) $ (2,000.00) $ (2,000.00)

Traditional Co-Pay Out of Pocket, In Network Max $ 4,000.00 $ 10,200.00 $ 10,200.00

Plus $ Prescription Out of Pocket Max $ 1,000.00 $ 3,000.00 $ 3,000.00

Plan Type Employee Only Employee + Spouse (no Employee + Children

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Tra

Employee + Family

$

10,200.00 $

3,000.00

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Aspen Heights Employer HSA Contribution Per Pay Period (24 in the Calendar Year)

Total Possible Employee Contribution if You Were Here for the Full 2018 Calendar Year

$ 2,450.00 $ 5,400.00 $ 5,400.00 $ 4,900.00 al $1,000 in catch up contributions

$ $ $ $

41.67 62.50 62.50 83.34

t be current employee for contributions starting at your benefit effective date

(1/1/2018-12/31/2018)

d contribute it to your ll have money in your

Difference Per Pay Period to set as your HSA Contribution $ 90.00 $ 175.30 $ 220.83 $ 307.15

Minus Aspen Heights' HSA Contribution over the full year (if spent 100% on medical costs, not including dental/vision) $ (1,000.00) $ (1,500.00) $ (1,500.00) $ (2,000.00)

Plus Employee Premiums Paid Over the Year $ 480.00 $ 900.00 $ 660.00 $ 1,200.00

Total Employee Exposure for 2018 (assuming all innetwork expenses) $ 2,480.00 $ 7,400.00 $ 7,160.00 $ 7,200.00

Plus Employee Minus $0 in HSA Contributions or Premiums Paid Back End Deductible Reimbursements Over the Year $ 2,640.00 $ $ $ 6,199.92 $ $ 4,867.20

Total Employee Exposure for 2018 (assuming all innetwork expenses) $ 7,640.00 $ 19,399.92 $ 18,067.20

ASPEN 2018 BENEFITS :: 18

$

-

$

8,571.60 $

Plan Type Employee Only Employee + Spouse (no children) Employee + Children Employee + Family

21,771.60

Difference Saved Over Traditional Co-Pay Plan Max Out of Pocket on Worst Case Scenario $ 5,160.00 $ 11,999.92 $ 10,907.20 $ 14,571.60

ASPEN 2018 BENEFITS :: 19

Total Possible Employee Contribution for the whole year divided into 24 pay periods (to max out your HSA if here for the whole calendar year)

$ $ $ $

102.08 225.00 225.00 204.17

ASPEN 2018 BENEFITS :: 20

ASPEN 2018 BENEFITS :: 21

2018 ****Note: All amounts on this worksheet assume you are paying a full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)**** ASPEN HEIGHTS HEALTH BENEFIT COMPARISON TOOL HSA (Health Spending Account): Aspen Heights 2018 Total IRS HSA Limit Employer HSA (Employee + Employer Contribution (full year) *** Contribution Limit) *

Plan Type

Employee Only $ 3,450.00 $ * Employees ages 55 or older can contribute an additional $1,000 in catch up contributions

1,000.00

Total Possible Employee Contribution if You Were Here for the Full 2018 Calendar Year

$

2,450.00

Aspen Heights Employer Contribution Per Pay Period (24 in the Calendar Year)

$

41.67

Total Possible Employee Contribution for the whole year divided into 24 pay periods (to max out your HSA)

$

102.08

***AH Contributions split over the 24 pay periods, must be current employee for contributions starting at your benefit effective date

High Deductible Health Plan: Aspen Heights also will reimburse you for the last $2000 to hit the deductible/out of pocket max.

Aspen Heights Reimburses Out-ofDeductible/ Max Out-of-Pocket Pocket Spending Over (after reaching this much of outThis Amount until the of-pocket spending the plan Employee Reaches the Deductible/Max Out of picks covers 100% of the $/year AH Contribution Pocket expenses) Plan Type 3,000.00 $ 5,000.00 Employee Only $ 1,000.00 $ ****NOTE THIS WORKSHEET ASSUMES YOU ARE USING IN NETWORK PROVIDERS ONLY****

Regular Buy-Up Plan

Example for Employee Only for 24 pay periods (full year) High Deductible Plan

Per Pay Period Amount from Paycheck

$

110.00

$

Total Yearly Cost if you never see a doctor (24 pay periods) Employer Contribution Total Yearly Cost if you never see a doctor

$ $ $

2,640.00 2,640.00

$ $ $

Max Out of Pocket Medical - Worst Case Scenario Max Out of Pocket Prescription - Worst Case Scenario Total Out of Pocket - Worst Case Scenario

$ $ $

4,000.00 1,000.00 7,640.00

$ $ $

Minus Employer Contribution Total Possible Out of Pocket

$

0 7,640.00

$ $

Difference saved if you never see a doctor 20.00 Per Pay Period Amount from Paycheck Total Yearly Cost if you never see a doctor (24 480.00 pay periods) $ 2,120.00 (1,000.00) Employer Contribution to your HSA for full year (520.00) actually gaining money with this plan

Enter Data in butter colored boxes

5,000.00 Max Out of Pocket - Worst Case Scenario no extra prescription out of pocket max 5,480.00 Total Out of Pocket - Worst Case Scenario ($1000 HSA contribution paid in per pay period Difference saved in worst case installments + last $2000 to meet deductible scenario (3,000.00) reimbursed) 2,480.00 Total Possible Out of Pocket $ 5,160.00

Scenario: Go to doctor 3 times ($400 retail each, or $35 co-pay in network) and 2 prescriptions per month ($125 retail each, $20 each on co-pay plan) Regular Buy-Up Plan High Deductible Plan 105.00 $ 1,200.00 Total for 3 Retail Doctor visits @ $400 each 480.00 $ 3,000.00 2 prescriptions Retail @125 each for 12 months subtotal out of pocket spending (deductible not $ 4,200.00 met)

Total for 3 Specialty Doctor visits @ $35 each (not subject to deductible) $

Prescriptions are not subject to deductible so 2 prescriptions at $20 co pay for 12 months $

cost of plan for year (just to have coverage) $

2,640.00

$

Total for 3 Retail Doctor visits, 2 Prescriptions for $20 CoPay for 12 months, and Coverage Cost $

3,225.00

$

$

$

$

cost of plan for year (just to have coverage, 480.00 does NOT go toward the deductible) Sub Total for 3 Retail Doctor visits, 2 Retail Prescriptions x 12 months @$125 each, and 4,680.00 Coverage Cost minus employer contribution (assumes your employer contribution for the full year) to your HSA and that you use it all on your medical (1,000.00) expenses instead of also on dental/vision. minus out of pocket reimbursement of anything between $3000-$5000 out of pocket spending (after $5000 the plan picks up at (1,200.00) 100%) Take the $4200 - $3000 = 1200 Total for 3 Retail Doctor visits, 2 Retail Prescriptions x 12 months @$125 each, and 2,480.00 Coverage Cost

Money Saved by choosing the High Deductible Plan $

745.00

****Note: All amounts on this worksheet assume full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)****

yes, you can enroll in the Dependent Care Account if you are contributing to an HSA account since they are to cover separate expenses.

If you put the difference between the two premiums into your Health Savings Account (taken out of your check as a Traditional Co Pay High Deductible payroll deduction, pre-tax) Premium Per Pay Period Premium Per Pay Period Difference Per Pay Period Employee Only $ 110.00 $ 20.00 $ 90.00 Look how much you can save for when you DO have medical/dental/vision expenses (either this year or any time in the future): **This example shows an employee who started in January, so their benefits became effective February 1st) Contribution Per pay Total in the account period Payroll Date Type of Contribution (Employee vs. Employer) 15-Feb Employer contribution $ 41.67 $ 41.67 DId you know you can change 15-Feb Employee Payroll Deduction $ 90.00 $ 131.67 your HSA deduction amount 28-Feb Employer contribution $ 41.67 $ 173.33 whenever you want during the 28-Feb Employee Payroll Deduction $ 90.00 $ 263.33 year?

15-Mar Employer contribution $ 41.67 $ 305.00 15-Mar Employee Payroll Deduction $ 90.00 $ 395.00 31-Mar Employer contribution $ 41.67 $ 436.67 31-Mar Employee Payroll Deduction $ 90.00 $ 526.67 15-Apr Employer contribution $ 41.67 $ 568.33 15-Apr Employee Payroll Deduction $ 90.00 $ 658.33 30-Apr Employer contribution $ 41.67 $ 700.00 30-Apr Employee Payroll Deduction $ 90.00 $ 790.00 15-May Employer contribution $ 41.67 $ 831.67 15-May Employee Payroll Deduction $ 90.00 $ 921.67 31-May Employer contribution $ 41.67 $ 963.33 31-May Employee Payroll Deduction $ 90.00 $ 1,053.33 15-Jun Employer contribution $ 41.67 $ 1,095.00 15-Jun Employee Payroll Deduction $ 90.00 $ 1,185.00 30-Jun Employer contribution $ 41.67 $ 1,226.67 30-Jun Employee Payroll Deduction $ 90.00 $ 1,316.67 15-Jul Employer contribution $ 41.67 $ 1,358.33 15-Jul Employee Payroll Deduction $ 90.00 $ 1,448.33

ASPEN 2018 BENEFITS :: 22

2018 ****Note: All amounts on this worksheet assume you are paying a full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)**** ASPEN HEIGHTS HEALTH BENEFIT COMPARISON TOOL HSA (Health Spending Account):

2018 Total IRS HSA Limit (Employee + Aspen Heights Employer Total Possible Employee Employer HSA Contribution (full Contribution if You Were Here Contribution Limit) * year) *** for the Full 2018 Calendar Year

Plan Type

Employee + Spouse $ 6,900.00 ***Amount Prorated to benefit eligibility date or activation date. ** Employees over 55 are eligible to make a catch up contribution of up to $1000 more.

$

1,500.00

$

5,400.00

Aspen Heights Employer Contribution Per Pay Period (24 in the Calendar Year)

$

62.50

Total Possible Employee Contribution for the whole year divided into 24 pay periods (to max out your HSA)

$

225.00

High Deductible Health Plan: Aspen Heights also will reimburse you for the last $2000 to hit the deductible.

Aspen Heights Reimburses Out-of-Pocket Spending Over This Amount until the Employee Reaches the $/year AH Deductible/Max Out of Contribution Pocket Plan Type Employee + Spouse (no children) $ 1,500.00 $ 8,000.00 ****NOTE THIS WORKSHEET ASSUMES YOU ARE USING IN NETWORK PROVIDERS ONLY****

Deductible/ Max Out-of-Pocket (after reaching this much of outMaximum Employee Exposure if the HSA is only of-pocket spending the plan spent on medical expenses (Not including cost of picks covers 100% of the expenses) HDHP Premiums) $ 10,000.00 $ 6,500.00

Example for Employee + Spouse for 24 pay periods (full year) Co-Pay Plan High Deductible Plan Per Pay Period Amount from Paycheck

$

258.33

$

Total Yearly Cost if you never see a doctor (24 pay periods) Employer Contribution Total Yearly Cost if you never see a doctor

$ $ $

6,199.92 6,199.92

$ $ $

Max Out of Pocket Medical - Worst Case Scenario Max Out of Pocket Prescription - Worst Case Scenario Total Out of Pocket - Worst Case Scenario

$ $ $

10,200.00 3,000.00 16,399.92

$ $ $

Minus Employer Contribution Total Possible Out of Pocket

$

0 16,399.92

$ $

37.50 Per Pay Period Amount from Paycheck Total Yearly Cost if you never see a doctor (24 pay 900.00 periods) (1,500.00) Employer Contribution to the HSA for full year (600.00) actually gaining money with this plan 10,000.00 Max Out of Pocket - Worst Case Scenario no extra prescription out of pocket max 10,900.00 Total Out of Pocket - Worst Case Scenario ($1500 HSA contribution paid in per pay period installments + last $2000 to meet deductible (3,500.00) reimbursed) 7,400.00 Total Possible Out of Pocket

Difference saved if you never see a doctor $

Enter Data in butter colored boxes

5,599.92

Difference saved in worst case scenario $ 8,999.92

Scenario: Go to doctor 3 times ($400 retail each, or $35 co-pay in network) and 2 prescriptions per month ($125 retail each, $20 each on co-pay plan) Regular Buy-Up Plan High Deductible Plan Total for 3 Specialty Doctor visits @ $35 each (not subject to deductible) $ 105.00 $ 1,200.00 Total for 3 Retail Doctor visits @ $400 each Prescriptions are not subject to deductible so 2 prescriptions at $20 co pay for 12 months $ 480.00 $ 3,000.00 2 prescriptions Retail @125 each for 12 months

cost of plan for year (just to have coverage) $

6,199.92

$ $

4,200.00 subtotal out of pocket spending (deductible not met) cost of plan for year (just to have coverage, does 900.00 NOT go toward the deductible)

Total for 3 Retail Doctor visits, 2 Prescriptions for $20 Co-Pay for 12 months, and Coverage Cost $

6,784.92

$

Sub Total for 3 Retail Doctor visits, 2 Retail Prescriptions x 12 months @$125 each, and 5,100.00 Coverage Cost

$

minus employer contribution (assumes your employer contribution for the full year) to your HSA and that you use it all on your medical expenses (1,500.00) instead of also on dental/vision. minus out of pocket reimbursement of anything between $8000-$10000 out of pocket spending (after $10,000 the plan picks up at 100% or after $5000 on one person the remaining $5000 deductible is for costs between the rest of the family) -

$

Total for 3 Retail Doctor visits, 2 Retail Prescriptions 3,600.00 x 12 months @$125 each, and Coverage Cost

$

Money Saved by choosing the High Deductible Plan $

In this example the family hasn't spent enough to qualify for the reimbursement

3,184.92

****Note: All amounts on this worksheet assume full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)****

yes, you can enroll in the Flexible Spending Account Dependent Care Account if you are contributing to an HSA account since they are to cover separate expenses.Â

If you put the difference between the two premiums into your Health Traditional Co Pay High Deductible Premium Savings Account (taken out of your check as a payroll deduction, pre- Premium Per Pay Per Pay Period Difference Per Pay Period tax) Period $ 258.33 $ 37.50 $ 220.83 Look how much you can save for when you DO have medical/dental/vision expenses (either this year or any time in the future): **This example shows an employee who started in January, so their benefits became effective February 1st) Contribution Per pay Total in the account Payroll Date Type of Contribution (Employee vs. Employer) period 15-Feb Employer contribution $ 62.50 $ 62.50 15-Feb Employee Payroll Deduction $ 220.83 $ 283.33 DId you know you can 28-Feb Employer contribution $ 62.50 $ 345.83 change your HSA 28-Feb Employee Payroll Deduction $ 220.83 $ 566.66 deduction amount 15-Mar Employer contribution $ 62.50 $ 629.16 whenever you want during 15-Mar Employee Payroll Deduction $ 220.83 $ 849.99 the year?

31-Mar Employer contribution $ 62.50 $ 912.49 31-Mar Employee Payroll Deduction $ 220.83 $ 1,133.32 15-Apr Employer contribution $ 62.50 $ 1,195.82 15-Apr Employee Payroll Deduction $ 220.83 $ 1,416.65 30-Apr Employer contribution $ 62.50 $ 1,479.15 30-Apr Employee Payroll Deduction $ 220.83 $ 1,699.98 15-May Employer contribution $ 62.50 $ 1,762.48 15-May Employee Payroll Deduction $ 220.83 $ 1,983.31 31-May Employer contribution $ 62.50 $ 2,045.81 31-May Employee Payroll Deduction $ 220.83 $ 2,266.64 15-Jun Employer contribution $ 62.50 $ 2,329.14 15-Jun Employee Payroll Deduction $ 220.83 $ 2,549.97 30-Jun Employer contribution $ 62.50 $ 2,612.47 30-Jun Employee Payroll Deduction $ 220.83 $ 2,833.30 15-Jul Employer contribution $ 62.50 $ 2,895.80 15-Jul Employee Payroll Deduction $ 220.83 $ 3,116.63

ASPEN 2018 BENEFITS :: 23

2018 ****Note: All amounts on this worksheet assume you are paying a full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)**** ASPEN HEIGHTS HEALTH BENEFIT COMPARISON TOOL HSA (Health Spending Account):

2018 Total IRS HSA Limit (Employee + Aspen Heights Employer Employer HSA Contribution (full Contribution Limit) * year) ***

Plan Type

Employee + Children $ 6,900.00 $ ***Amount Prorated to benefit eligibility date or activation date. ** Employees over 55 are eligible to make a catch up contribution of up to $1000 more.

1,500.00

Total Possible Employee Contribution if You Were Here for the Full 2018 Calendar Year

$

Aspen Heights Employer Contribution Per Pay Period (24 in the Calendar Year)

5,400.00

$

62.50

Total Possible Employee Contribution for the whole year divided into 24 pay periods (to max out your HSA)

$

225.00

High Deductible Health Plan: Aspen Heights also will reimburse you for the last $2000 to hit the deductible.

Aspen Heights Reimburses Out-of-Pocket Spending Over This Amount until the Employee Reaches the $/year AH Deductible/Max Out of Contribution Plan Type Pocket Employee + Children $ 1,500.00 $ 8,000.00 ****NOTE THIS WORKSHEET ASSUMES YOU ARE USING IN NETWORK PROVIDERS ONLY****

Deductible/ Max Out-ofPocket (after reaching this much of out-of-pocket spending the plan picks covers 100% of the expenses) $ 10,000.00

Example for Employee + Children for 24 pay periods (full year) Regular Co-Pay Plan High Deductible Plan Per Pay Period Amount from Paycheck Total Yearly Cost if you never see a doctor (24 pay periods) Employer Contribution Total Yearly Cost if you never see a doctor

$

202.80

$

$ $ $

4,867.20 4,867.20

$ $ $

Max Out of Pocket Medical - Worst Case Scenario $ Max Out of Pocket Prescription - Worst Case Scenario $ Total Out of Pocket - Worst Case Scenario $

10,200.00 3,000.00 18,067.20

$ $ $

Minus Employer Contribution Total Possible Out of Pocket

0 18,067.20

$ $

$

27.50 Per Pay Period Amount from Paycheck Total Yearly Cost if you never see a doctor 660.00 (24 pay periods) (1,500.00) Employer Contribution for full year (840.00) actually gaining money with this plan

Difference saved if you never see a doctor $

Enter Data in butter colored boxes

4,027.20

10,000.00 Max Out of Pocket - Worst Case Scenario no separate out of pocket max for prescriptions 10,660.00 Total Out of Pocket - Worst Case Scenario ($1500 HSA contribution paid in per pay period Difference saved in worst installments + last $2000 to meet deductible case scenario (3,500.00) reimbursed) 7,160.00 Total Possible Out of Pocket $ 10,907.20

Scenario: Go to doctor 3 times ($400 retail each, or $35 co-pay in network) and 2 prescriptions per month ($125 retail each, $20 each on co-pay plan) Regular Buy-Up Plan High Deductible Plan Total for 3 Specialty Doctor visits @ $35 each (not subject to deductible) $ 105.00 $ 1,200.00 Total for 3 Retail Doctor visits @ $400 each 480.00 $ 3,000.00 2 prescriptions Retail @125 each for 12 months subtotal out of pocket spending (deductible $ 4,200.00 not met)

Prescriptions are not subject to deductible so 2 prescriptions at $20 co pay for 12 months $

cost of plan for year (just to have coverage) $

4,867.20

$

Total for 3 Retail Doctor visits, 2 Prescriptions for $20 CoPay for 12 months, and Coverage Cost $

5,452.20

$

cost of plan for year (just to have coverage, 660.00 does NOT go toward the deductible) Sub Total for 3 Retail Doctor visits, 2 Retail Prescriptions x 12 months @$125 each, and 4,860.00 Coverage Cost

$

minus employer contribution (assumes your employer contribution for the full year) to your HSA and that you use it all on your medical (1,500.00) expenses instead of also on dental/vision.

$

minus out of pocket reimbursement of anything between $8000-$10000 out of pocket spending (after $10,000 the plan picks up at 100% or after $5000 on one person the remaining $5000 deductible is for costs between the rest of the family)

$ Money Saved by choosing the High Deductible Plan $

Total for 3 Retail Doctor visits, 2 Retail Prescriptions x 12 months @$125 each, and 3,360.00 Coverage Cost

In this example the family hasn't spent enough to qualify for the reimbursement

2,092.20

****Note: All amounts on this worksheet assume full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)****

yes, you can enroll in the Flexible Spending Account Dependent Care Account if you are contributing to an HSA account since they are to cover separate expenses.Â

Traditional Co Pay Premium Per Pay High Deductible Premium Period Difference Per Pay Period Per Pay Period $ 202.80 $ 27.50 $ 175.30 Look how much you can save for when you DO have medical/dental/vision expenses (either this year or any time in the future): **This example shows an employee who started in January, so their benefits became effective February 1st) Contribution Per pay Total in the account Payroll Date Type of Contribution (Employee vs. Employer) period DId you know you can 15-Feb Employer contribution $ 62.50 $ 62.50 change your HSA deduction 15-Feb Employee Payroll Deduction $ 175.30 $ 175.30 amount whenever you want 28-Feb Employer contribution $ 62.50 $ 62.50 during the year?

28-Feb Employee Payroll Deduction $ 175.30 $ 175.30 15-Mar Employer contribution $ 62.50 $ 62.50 15-Mar Employee Payroll Deduction $ 175.30 $ 175.30 31-Mar Employer contribution $ 62.50 $ 62.50 31-Mar Employee Payroll Deduction $ 175.30 $ 175.30 15-Apr Employer contribution $ 62.50 $ 62.50 15-Apr Employee Payroll Deduction $ 175.30 $ 175.30 30-Apr Employer contribution $ 62.50 $ 62.50 30-Apr Employee Payroll Deduction $ 175.30 $ 175.30 15-May Employer contribution $ 62.50 $ 62.50 15-May Employee Payroll Deduction $ 175.30 $ 175.30 31-May Employer contribution $ 62.50 $ 62.50 31-May Employee Payroll Deduction $ 175.30 $ 175.30 15-Jun Employer contribution $ 62.50 $ 62.50 15-Jun Employee Payroll Deduction $ 175.30 $ 175.30 30-Jun Employer contribution $ 62.50 $ 62.50 30-Jun Employee Payroll Deduction $ 175.30 $ 175.30 15-Jul Employer contribution $ 62.50 $ 62.50 15-Jul Employee Payroll Deduction $ 175.30 $ 175.30 If you put the difference between the two premiums into your Health Savings Account (taken out of your check as a payroll deduction, pre-tax)

ASPEN 2018 BENEFITS :: 24

2018 ****Note: All amounts on this worksheet assume you are paying a full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)**** ASPEN HEIGHTS HEALTH BENEFIT COMPARISON TOOL HSA (Health Spending Account):

Aspen Heights Employer HSA 2018 Total IRS HSA Limit (Employee + Contribution (full year) *** Employer Contribution Limit) *

Plan Type

Employee + Family $ ***Amount Prorated to benefit eligibility date or activation date. ** Employees over 55 are eligible to make a catch up contribution of up to $1000 more.

6,900.00

$

2,000.00

Total Possible Employee Contribution if You Were Here for the Full 2018 Calendar Year

$

4,900.00

Total Possible Employee Contribution for the whole year divided into 24 Aspen Heights Employer pay periods (to Contribution Per Pay Period (24 max out your in the Calendar Year) HSA)

$

83.34

$

204.17

High Deductible Health Plan: Aspen Heights also will reimburse you for the last $2000 to hit the deductible.

Aspen Heights Reimburses Out-ofPocket Spending Over This Amount until the Employee Reaches the Deductible/Max Out of Pocket $/year AH Contribution Plan Type Employee + Spouse + Children (AKA Emloyee + Family) $ 2,000.00 $ 8,000.00 ****NOTE THIS WORKSHEET ASSUMES YOU ARE USING IN NETWORK PROVIDERS ONLY****

Deductible/ Max Out-of-Pocket (after reaching this much of outof-pocket spending the plan picks covers 100% of the expenses) $ 10,000.00

Example for Employee + Family for 24 pay periods (full year, assuming all providers are in-network) Co-Pay Plan High Deductible Plan $ 357.15 $ 50.00 Per Pay Period Amount from Paycheck Total Yearly Cost if you never see a doctor (24 Total Yearly Cost if you never see a doctor (24 pay periods) $ 8,571.60 $ 1,200.00 pay periods) Per Pay Period Amount from Paycheck

$ $

8,571.60

$ $

(2,000.00) Employer Contribution to your HSA for full year (800.00) actually gaining money with this plan

Max Out of Pocket Medical - Worst Case Scenario $ Max Out of Pocket Prescription - Worst Case Scenario $ Total Out of Pocket - Worst Case Scenario $

10,200.00 3,000.00 18,771.60

$ $ $

0 18,771.60

$ $

10,000.00 Max Out of Pocket - Worst Case Scenario no extra prescription out of pocket max 11,200.00 Total Out of Pocket - Worst Case Scenario ($2000 HSA contribution paid in per pay period installments + last $2000 to meet deductible (4,000.00) reimbursed) 7,200.00 Total Possible Out of Pocket

Employer Contribution Total Yearly Cost if you never see a doctor

Minus Employer Contribution Total Possible Out of Pocket

$

Enter Data in butter colored boxes

Difference saved if you never see a doctor $

7,771.60

Difference Saved Worse Case Scenario $ 11,571.60

Scenario: Go to doctor 3 times ($400 retail each, or $35 co-pay in network) and 2 prescriptions per month ($125 retail each, $20 each on co-pay plan) Regular Buy-Up Plan High Deductible Plan 105.00 $ 1,200.00 Total for 3 Retail Doctor visits @ $400 each 480.00 $ 3,000.00 2 prescriptions Retail @125 each for 12 months subtotal out of pocket spending (deductible not $ 4,200.00 met)

Total for 3 Specialty Doctor visits @ $35 each (not subject to deductible) $ Prescriptions are not subject to deductible so 2 prescriptions at $20 co pay for 12 months $

cost of plan for year (just to have coverage) $

8,571.60

$

Total for 3 Retail Doctor visits, 2 Prescriptions for $20 Co-Pay for 12 months, and Coverage Cost $

9,156.60

$

$

$

$ Money Saved by choosing the High Deductible Plan $

cost of plan for year (just to have coverage, does 1,200.00 NOT go toward the deductible) Sub Total for 3 Retail Doctor visits, 2 Retail Prescriptions x 12 months @$125 each, and 5,400.00 Coverage Cost minus employer contribution (assumes your employer contribution for the full year) to your HSA and that you use it all on your medical (2,000.00) expenses instead of also on dental/vision. minus out of pocket reimbursement of anything between $8000-$10000 out of pocket spending (after $10,000 the plan picks up at 100% or after $5000 on one person the remaining $5000 deductible is for costs between the rest of the family) Total for 3 Retail Doctor visits, 2 Retail Prescriptions x 12 months @$125 each, and 3,400.00 Coverage Cost

In this example the family hasn't spent enough to qualify for the reimbursement

5,756.60

****Note: All amounts on this worksheet assume full year's worth of premiums, receiving a full year's worth of Aspen Heights Employer HSA Contributions, only saw in network providers, and that you used your HSA only for medical expenses (not on dental or vision)****

yes, you can enroll in the Flexible Spending Account Dependent Care Account if you are contributing to an HSA account since they are to cover separate expenses.Â

If you put the difference between the two premiums into your Health Savings Traditional Co Pay Account (taken out of your check as a Premium Per Pay High Deductible Premium Per payroll deduction, pre-tax) Period Pay Period Difference Per Pay Period $ 357.15 $ 50.00 $ 307.15 Look how much you can save for when you DO have medical/dental/vision expenses (either this year or any time in the future): **This example shows an employee who started in January, so their benefits became effective February 1st) Type of Contribution (Employee vs.

Contribution Per pay Payroll Date Employer) period Total in the account 15-Feb Employer contribution $ 83.34 $ 83.34 DId you know you can change your 15-Feb Employee Payroll Deduction $ 307.15 $ 390.49 HSA deduction amount whenever 28-Feb Employer contribution $ 83.34 $ 473.83 you want during the year?

28-Feb Employee Payroll Deduction $ 307.15 $ 780.98 15-Mar Employer contribution $ 83.34 $ 864.32 15-Mar Employee Payroll Deduction $ 307.15 $ 1,171.47 31-Mar Employer contribution $ 83.34 $ 1,254.81 31-Mar Employee Payroll Deduction $ 307.15 $ 1,561.96 15-Apr Employer contribution $ 83.34 $ 1,645.30 15-Apr Employee Payroll Deduction $ 307.15 $ 1,952.45 30-Apr Employer contribution $ 83.34 $ 2,035.79 30-Apr Employee Payroll Deduction $ 307.15 $ 2,342.94 15-May Employer contribution $ 83.34 $ 2,426.28 15-May Employee Payroll Deduction $ 307.15 $ 2,733.43 31-May Employer contribution $ 83.34 $ 2,816.77 31-May Employee Payroll Deduction $ 307.15 $ 3,123.92 15-Jun Employer contribution $ 83.34 $ 3,207.26 15-Jun Employee Payroll Deduction $ 307.15 $ 3,514.41 30-Jun Employer contribution $ 83.34 $ 3,597.75 30-Jun Employee Payroll Deduction $ 307.15 $ 3,904.90 15-Jul Employer contribution $ 83.34 $ 3,988.24 15-Jul Employee Payroll Deduction

$

307.15

$

4,295.39 You're already almost maxed out for the year!

ASPEN 2018 BENEFITS :: 25

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services BRG Management dba Aspen Heights Group: HSA Plan

Coverage Period: 01/01/2018 – 12/31/2018 Coverage for: Individual + Family | Plan Type: HSA

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-521-2227 or at https://policy-srv.box.com/s/ckwqt2hnw7m5d9qvw7pbtx8i4wxd8hwv.

For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/UG-Glossary-508-MM.pdf or call 1-800-521-2227 to request a copy.

Important Questions

Answers

What is the overall deductible?

For In-Network $5,000 Individual/$10,000 Family For Out-of-Network $10,000 Individual/$20,000 Family

Are there services covered before you meet your deductible?

Yes. Certain preventive care is covered before you meet your deductible.

Are there other deductibles for specific services?

No.

What is the out-ofpocket limit for this plan?

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

For In-Network $5,000 Individual/$10,000 Family For Out-of-Network $20,000 Individual/$40,000 Family Premiums, balance-billed charges, preauthorization penalties, and health care this plan doesn’t cover.

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of network providers.

Do you need a referral to No. see a specialist?

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

You don’t have to meet deductibles for specific services.

The out-of-pocket limit is the most you could pay in a year for covered services.

If you have other family members in this plan, they have to meet their own outof-pocket limits until the overall family out-of-pocket limit has been met.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an Out-of-Network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an Out-of-Network provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

1 of 6:: 26 ASPEN 2018 BENEFITS

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

If you visit a health care provider’s office or clinic

Services You May Need Primary care visit to treat an injury or illness Specialist visit

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Limitations, Exceptions, & Other Important Information

No Charge

30% coinsurance

None

No Charge

30% coinsurance

Preventive care/screening/ immunization

No Charge; deductible does not apply

30% coinsurance

None You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

No Charge for child immunizations Out-ofNetwork through the 6th birthday.

Diagnostic test (x-ray, blood work)

No Charge

30% coinsurance

None

Imaging (CT/PET scans, MRIs)

No Charge

30% coinsurance

None

Generic drugs

No Charge

No Charge

Preferred brand drugs

No Charge

No Charge

Non-preferred brand drugs

No Charge

No Charge

Retail and mail order cover a 30 day supply. With appropriate prescription, up to a 90 day supply is available.

For non-participating pharmacy, member must file claim.

Non-participating mail order is not

If you have a test

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com If you have outpatient surgery If you need immediate medical attention

covered.

No Charge

Available at any retail pharmacy.

Mail order is not covered

Facility fee (e.g., ambulatory surgery No Charge center)

30% coinsurance

None

Physician/surgeon fees

No Charge

30% coinsurance

None

Emergency room care Emergency medical transportation

No Charge No Charge

No Charge No Charge

None Ground and air transportation covered.

Urgent care

No Charge

30% coinsurance

None

Specialty drugs

No Charge

* For more information about limitations and exceptions, see the plan or policy document at 2 of ::627 ASPEN 2018 BENEFITS

Common Medical Event If you have a hospital stay If you need mental health, behavioral health, or substance abuse services

If you are pregnant

Facility fee (e.g., hospital room)

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) No Charge 30% coinsurance

Physician/surgeon fees

No Charge

30% coinsurance

Outpatient services

No Charge

30% coinsurance

Services You May Need

Limitations, Exceptions, & Other Important Information None Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Certain services must be preauthorized; refer to benefits booklet for details.

All services must be preauthorized. $250 penalty if services are not preauthorized Out-of-Network.

Inpatient services

No Charge

30% coinsurance

Office visits

No Charge

30% coinsurance

Childbirth/delivery professional services

No Charge

30% coinsurance

Childbirth/delivery facility services

No Charge

30% coinsurance

Home health care

No Charge

30% coinsurance

Rehabilitation services

No Charge

30% coinsurance

No Charge

30% coinsurance

No Charge

30% coinsurance

Preauthorization is required.

Limited to 25 days per calendar year

Durable medical equipment

No Charge

30% coinsurance

None

Hospice services

No Charge

30% coinsurance

Preauthorization is required.

If you need help recovering or have Habilitation services other special health needs Skilled nursing care

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Preauthorization is required.

Limited to 60 visits per calendar year Limited to 35 visits combined for all therapies per calendar year. Includes, but is not limited to, physical, occupational, manipulative and speech therapy.

* For more information about limitations and exceptions, see the plan or policy document at 3 of ::628 ASPEN 2018 BENEFITS

Common Medical Event If your child needs dental or eye care

Services You May Need Children’s eye exam Children’s glasses Children’s dental check-up

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) No Charge 30% coinsurance Not Covered Not Covered Not Covered Not Covered

Limitations, Exceptions, & Other Important Information None None None

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)    

Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult)

   

Infertility treatment Long term care Non-emergency care when traveling outside the U.S. Private-duty nursing

 Routine foot care  Routine eye care (Adult)  Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Chiropractic care

 Hearing aids (limited to 1 new aid per ear per 36month period)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at 1-800-521-2227, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.

Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. * For more information about limitations and exceptions, see the plan or policy document at 4 of ::629 ASPEN 2018 BENEFITS

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

5 of 6 ASPEN 2018 BENEFITS :: 30

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)  The plan’s overall deductible  Specialist coinsurance  Hospital (facility) coinsurance  Other coinsurance

$5,000 0% 0% 0%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

$12,800

$5,000 $0 $0 $60 $5,060

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a wellcontrolled condition)  The plan’s overall deductible  Specialist coinsurance  Hospital (facility) coinsurance  Other coinsurance

$5,000 0% 0% 0%

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

$7,400

$5,000 $0 $0 $60 $5,060

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)  The plan’s overall deductible  Specialist coinsurance  Hospital (facility) coinsurance  Other coinsurance

$5,000 0% 0% 0%

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost

$1,900

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services.

$1,900 $0 $0 $0 $1,900

6 of 6

ASPEN 2018 BENEFITS :: 31

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ASPEN 2018 BENEFITS :: 32

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services 200 Independence Avenue SW Room 509F, HHH Building 1019 Washington, DC 20201

Phone: 800-368-1019 TTY/TDD: 800-537-7697 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

.

ASPEN 2018 BENEFITS :: 33

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services BRG Management dba Aspen Heights Group: PPO Plan

Coverage Period: 01/01/2018 – 12/31/2018 Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-521-2227 or at https://policy-srv.box.com/s/ogorruaafyjjj0xpf66quei3xcszu71t.

For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/UG-Glossary-508-MM.pdf or call 1-800-521-2227 to request a copy.

Important Questions

Answers

What is the overall deductible?

For In-Network $1,000 Individual/$3,000 Family For Out-of-Network $2,000 Individual/$6,000 Family

Are there services covered before you meet your deductible?

Yes. Services that charge a copay, prescription drugs, and certain preventive care, diagnostic test, home health, skilled nursing, and hospice are covered before you meet your deductible.

Are there other deductibles for specific services?

Yes. Per occurrence: $250 Out-of-Network inpatient admission. There are no other specific deductibles.

What is the out-ofpocket limit for this plan?

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

For In-Network $4,000 Individual/$10,200 Family For Out-of-Network $8,000 Individual/$24,000 Family Prescription drug expense limit: $1,000 Individual / $3,000 Family Premiums, balance-billed charges, preauthorization penalties, and health care this plan doesn’t cover.

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of network providers.

Do you need a referral to No. see a specialist?

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

The out-of-pocket limit is the most you could pay in a year for covered services.

If you have other family members in this plan, they have to meet their own outof-pocket limits until the overall family out-of-pocket limit has been met.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an Out-of-Network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an Out-of-Network provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

1 of 6:: 34 ASPEN 2018 BENEFITS

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) $25 copay/visit; 30% coinsurance deductible does not apply $25 copay/visit; 30% coinsurance deductible does not apply

None

Preventive care/screening/ immunization

No Charge; deductible does not apply

30% coinsurance

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

No Charge for child immunizations Out-ofNetwork through the 6th birthday.

Diagnostic test (x-ray, blood work)

No Charge; deductible does not apply

30% coinsurance

None

Imaging (CT/PET scans, MRIs)

20% coinsurance

40% coinsurance

None

$20 retail and mail order copay/ prescription; deductible does not apply $35 retail and mail order copay/ prescription; deductible does not apply

$20 copay/prescription plus 20% coinsurance; deductible does not apply $35 copay/prescription plus 20% coinsurance; deductible does not apply

$50 retail and mail order copay/ prescription; deductible does not apply

$50 copay/prescription plus 20% coinsurance; deductible does not apply

Prescription drug out-of-pocket limit: $1,000 Individual/$3,000 Family Retail and mail order cover a 30 day supply. With appropriate prescription, up to a 90 day supply is available.

For non-participating pharmacy, member must file claim.

Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available.

Non-participating mail order is not

Services You May Need Primary care visit to treat an injury or illness

If you visit a health care provider’s office or clinic

Specialist visit

If you have a test

Generic drugs

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com

Preferred brand drugs

Non-preferred brand drugs

Limitations, Exceptions, & Other Important Information

None

covered.

Specialty drugs

$20/$30/$50 copay/prescription; deductible does not apply

$20/$30/$50 copay/prescription plus 20% coinsurance; deductible does not apply

For In-Network benefit, must be obtained from Prime Specialty Pharmacy.

Mail order is not covered

* For more information about limitations and exceptions, see the plan or policy document at 2 of ::635 ASPEN 2018 BENEFITS

Common Medical Event If you have outpatient surgery

If you need immediate medical attention

Services You May Need

If you need mental health, behavioral health, or substance abuse services

If you are pregnant

Limitations, Exceptions, & Other Important Information

Facility fee (e.g., ambulatory surgery 20% coinsurance center)

40% coinsurance

None

Physician/surgeon fees

20% coinsurance

40% coinsurance

None

$100 copay/visit plus 20% coinsurance; deductible does not apply 20% coinsurance

Facility fee (e.g., hospital room)

$100 copay/visit plus 20% coinsurance; deductible does not apply 20% coinsurance $50 copay/visit; deductible does not apply 20% coinsurance

Physician/surgeon fees

20% coinsurance

40% coinsurance

Outpatient services

$25 copay/visit; deductible does not apply

30% coinsurance

Certain services must be preauthorized; refer to benefits booklet for details.

40% coinsurance

All services must be preauthorized. $250 penalty if services are not preauthorized Out-of-Network.

Emergency room care Emergency medical transportation Urgent care

If you have a hospital stay

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

None

40% coinsurance

None Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

20% coinsurance

Office visits

$25 copay/visit; deductible does not apply

30% coinsurance

Childbirth/delivery professional services

20% coinsurance

40% coinsurance

20% coinsurance

Ground and air transportation covered.

30% coinsurance

Inpatient services

Childbirth/delivery facility services

Emergency room copay waived if admitted.

40% coinsurance

Copay applies to first prenatal visit (per pregnancy.

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

* For more information about limitations and exceptions, see the plan or policy document at 3 of ::636 ASPEN 2018 BENEFITS

Common Medical Event

Services You May Need

Limitations, Exceptions, & Other Important Information Preauthorization is required.

Limited to 60 visits per calendar year

Home health care

No Charge; deductible does not apply

30% coinsurance

Rehabilitation services

20% coinsurance

40% coinsurance

20% coinsurance

40% coinsurance

No Charge; deductible does not apply

30% coinsurance

Preauthorization is required.

Limited to 25 days per calendar year

Durable medical equipment

20% coinsurance

40% coinsurance

None

Hospice services

No Charge; deductible does not apply

30% coinsurance

Preauthorization is required.

30% coinsurance

None

Not Covered Not Covered

None None

If you need help Habilitation services recovering or have other special health Skilled nursing care needs

If your child needs dental or eye care

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Children’s eye exam Children’s glasses Children’s dental check-up

$25 copay/visit; deductible does not apply Not Covered Not Covered

Limited to 35 visits combined for all therapies per calendar year. Includes, but is not limited to, physical, occupational, manipulative and speech therapy.

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)    

Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult)

   

Infertility treatment Long term care Non-emergency care when traveling outside the U.S. Private-duty nursing

 Routine foot care  Routine eye care (Adult)  Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Chiropractic care

 Hearing aids (limited to 1 new aid per ear per 36month period)

* For more information about limitations and exceptions, see the plan or policy document at 4 of ::637 ASPEN 2018 BENEFITS

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at 1-800-521-2227, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.

Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

5 of 6 ASPEN 2018 BENEFITS :: 38

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)  The plan’s overall deductible  Specialist copayment  Hospital (facility) coinsurance  Other coinsurance

$1,000 $25 20% 0%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

$12,800

$1,000 $100 $2,100 $60 $3,260

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a wellcontrolled condition)  The plan’s overall deductible  Specialist copayment  Hospital (facility) coinsurance  Other coinsurance

$1,000 $25 20% 0%

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

$7,400

$1,000 $1,100 $100 $60 $2,260

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)  The plan’s overall deductible  Specialist copayment  Hospital (facility) coinsurance  Other coinsurance

$1,000 $25 20% 0%

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost

$1,900

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services.

$1,100 $200 $70 $0 $1,270

6 of 6

ASPEN 2018 BENEFITS :: 39

.

ASPEN 2018 BENEFITS :: 40

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services 200 Independence Avenue SW Room 509F, HHH Building 1019 Washington, DC 20201

Phone: 800-368-1019 TTY/TDD: 800-537-7697 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

.

ASPEN 2018 BENEFITS :: 41

Scan the QR code to download the Mobile App!

Aspen Heights' Telemedicine Benefit 24/7/365

phone and video access to U.S.-based physicians

888-691-7867

Beginning December 1, 2017!

Feel sick?

• Diagnosis and treatment provided conveniently via phone and video • Prescriptions when appropriate • No copay or consultation fee

Call a doctor.

• Provided by Aspen Heights to all employees enrolled in the medical plan and their covered dependents.

Get on with life!

ASPEN 2018 BENEFITS :: 42

Beginning December 1, 2017!

Call 888-691-7867 to speak to a physician What to Expect:

Top 10 Reasons Members Call First Stop Health

• Available 24/7/365 • Unlimited consultations • U.S.-based physicians • Physicians licensed in 50 states • No copays or fees to use the service • 86% of calls to First Stop Health prevent unnecessary trips to doctors’ offices and ERs • Includes immediate family members • Confidential medical dashboard with record of consultations + tools to upload and share medical records

1 2 3 4 5 6 7 8 9 10

Sore Throat Cough Sinus Infection Urinary Tract Infection Skin Rash Eye Infection Ear Ache Upset Stomach Muscle/Joint Pain Medication Refill

To learn more about First Stop Health telemedicine services, contact: “I used First Stop Health and it is terrific. I’m at the airport now, leaving for my honeymoon with prescription in hand. Lifesaver!”

–Laura S., First Stop Health Member

www.fshealth.com 888.691.7867 222 N. Columbus Dr., Suite D Chicago, IL 60601

ASPEN 2018 BENEFITS :: 43

Scan the QR code to download the Mobile App!

New Benefit Beginning December 1, 2017!

24/7 ACCESS TO U.S.-BASED PHYSICIANS ON DEMAND VIA TELEMEDICINE First Stop Health’s telemedicine solution makes everyday healthcare even easier for Aspen Heights employees enrolled in the medical plan!

• • • • • •

Call 888-691-7867 to talk to a doctor in minutes FREE to use; there are no copays or consultation fees to use this service Consultations can be completed by phone or video Your dependents are also eligible to use the service No online registration is required to access a doctor, just call us!

Prescriptions are available if indicated, or a refill of a maintenance medication is needed. Prescription copays apply.

Common conditions treated via telemedicine: • • • • • • • •

infections (e.g., urinary, ear, upper respiratory, eye, etc.); sinus or allergy-related problems; sore throat & cough; colds & flu; swelling and/or soreness; nausea and/or vomiting; rashes; and other minor illness & injuries

Mobile App

First Stop Health’s mobile app is available to download from the App Store or Google Play store. Login to request consultations in seconds.

Online Medical Dashboard

Your consultations with First Stop Health physicians are recorded and available on your secure, online dashboard. In addition, you can create and store records for you and your family members. Have everything at your fingertips so you can send records to doctors, ensuring continuity of care.

Family Members Included

Up to seven family members (e.g., spouse, parent, child) can be included on your plan. Like you, your family members can call as often as they need.

First Stop Health Doctors

All First Stop Health doctors have completed residencies in family medicine, internal medicine, or emergency medicine. The doctors are U.S. based and licensed to practice in the state from where you are calling.

ASPEN 2018 BENEFITS :: 44

Dental

Plan Design for: BRG Management Inc dba Aspen Heights Date Prepared: February 28, 2017 The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a healthier smile and a healthier you.

Coverage Type: Type A - Preventive Type B - Basic Restorative Type C - Major Restorative Type D - Orthodontia

In-Network1 % of PDP Fee 100% 100% 60% 50%

2

Out-of-Network1 % of PDP Fee2 100% 100% 60% 50%

Deductible3 Individual Family

$50 $150

$50 $150

$1750

$1750

Annual Maximum Benefit: Per Individual Orthodontia Lifetime Maximum Ortho applies to Adult and Child

1.

2.

3.

Up to dependent age limit $1500 per Person $1500 per Person

"In-Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist.

Negotiated fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

Applies to Type B and C services only.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ŠUnited Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 45

Selected Covered Services and Frequency Limitations* Type A - Preventive Y4

Oral Examinations Full Mouth X-rays Bitewing X-rays (Adult/Child) Prophylaxis - Cleanings Topical Fluoride Applications Sealants Space Maintainers Emergency Palliative Treatment Harmful Habits Appliances

How Many/How Often: 1 in 6 months 1 in 60 months 1 in 12 months 1 in 6 months 2 in 12 months - Children to age 14 1 in 36 months - Children to age 16 1 per lifetime per tooth area - Children up to age 16

Type B - Basic Restorative Amalgam and Composite Fillings Prefabricated Crowns Endodontics Root Canal Periodontal Surgery Periodontal Scaling & Root Planing Periodontal Maintenance Oral Surgery (Simple Extractions) Oral Surgery (Surgical Extractions) Other Oral Surgery General Anesthesia Consultations

How Many/How Often: 1 in 24 months. All teeth 1 per tooth in 24 months 1 per tooth per lifetime 1 in 36 months per quadrant 1 in 24 months per quadrant 2 in 1 year, includes 2 cleanings

1 in 12 months

Type C - Major Restorative Crowns/Inlays/Onlays Repairs Bridges Dentures Implant Services TMJ

How Many/How Often: 1 per tooth in 10 years 1 in 12 months 1 in 10 years 1 in 10 years 1 service per tooth in 10 years - 1 repair per 10 years Major Service as part of Annual Maximum.

Type D – Orthodontia · · ·

·

Adult and Child Coverage. Dependent children up to age 26. Age limitations may vary by state. Please see your Plan description for complete details. In the event of a conflict with this summary, the terms of the certificate will govern.

All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.

Benefits for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for Orthodontia. Periodic follow-up visits will be payable on a monthly basis during the scheduled course of the orthodontic treatment. Allowable expenses for the initial placement, periodic follow-up visits and procedures performed in connection with the orthodontic treatment, are all subject to the Orthodontia coinsurance level and Lifetime Maximum Benefit Amount as defined in the Plan Summary.

Orthodontic benefits end at cancellation of coverage

*Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you receive a more costly treatment alternative, your dentist may charge you or your dependent for the difference between the cost of the service that was performed and the least costly treatment alternative.

The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 46

We will not pay Dental Insurance benefits for charges incurred for: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature; Services for which You would not be required to pay in the absence of Dental Insurance; Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate).

Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: · scaling and polishing of teeth; or · fluoride treatments.

For NY Sitused Groups, this exclusion does not apply.

Services or appliances which restore or alter occlusion or vertical dimension.

Restoration of tooth structure damaged by attrition, abrasion or erosion.

Restorations or appliances used for the purpose of periodontal splinting.

Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.

Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.

Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.

Missed appointments.

Services · covered under any workers’ compensation or occupational disease law; · covered under any employer liability law; · for which the employer of the person receiving such services is not required to pay; or · received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

For North Carolina and Virginia Sitused Groups, this exclusion does not apply.

Services paid under any worker’s compensation, occupational disease or employer liability law as follows: · for persons who are covered in North Carolina for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act; · or for persons who are not covered in North Carolina, services paid or payable under any workers compensation or occupational disease law.

This exclusion only applies for North Carolina Sitused Groups.

Services: · for which the employer of the person receiving such services is not required to pay; or · received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

This exclusion only applies for North Carolina Sitused Groups.

Services covered under any workers' compensation, occupational disease or employer liability law for which the employee/or Dependent received benefits under that law.

This exclusion only applies for Virginia Sitused Groups.

Services: · for which the employer of the person receiving such services is not required to pay; or · received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital.

This exclusion only applies for Virginia Sitused Groups.

Services covered under other coverage provided by the Employer.

Temporary or provisional restorations.

Temporary or provisional appliances.

Prescription drugs.

Services for which the submitted documentation indicates a poor prognosis.

The following when charged by the Dentist on a separate basis: · claim form completion; · infection control such as gloves, masks, and sterilization of supplies; or · local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.

Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food.

For NY Sitused Groups, this exclusion does not apply.

Caries susceptibility tests.

Other fixed Denture prosthetic services not described elsewhere in this certificate.

Precision attachments, except when the precision attachment is related to implant prosthetics.

Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it.

Repair or replacement of an orthodontic device.1 Duplicate prosthetic devices or appliances.

Replacement of a lost or stolen appliance, Cast Restoration, or Denture.

Intra and extraoral photographic images.

Services or supplies furnished as a result of a referral prohibited by Section 1-302 of the Maryland Health Occupations Article.

A prohibited referral is one in which a Health Care Practitioner refers You to a Health Care Entity in which the Health Care Practitioner or Health Care Practitioner’s immediate family or both own a Beneficial Interest or have a Compensation Agreement. For the purposes of this exclusion, the terms “Referral”, “Health Care Practitioner” , “Health Care Entity”,

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 47

“Beneficial Interest” and Compensation Agreement have the same meaning as provided in Section 1-301 of the Maryland Health Occupations Article.

This exclusion only applies for Maryland Sitused Groups 1Some

of these exclusions may not apply. Please see your plan design and certificate for details.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 48

Common Questions … Important Answers Who is a participating dentist?

A participating, or network, dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in full for covered services provided to plan members, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees typically range from 15-45% below the average fees charged in a dentist’s community for the same or substantially similar services.* In addition to the standard MetLife network, your employer may provide you with access to a select network of dental providers that may be unique to your employer’s dental program. When visiting these providers, you may receive a better benefit, have lower out-of-pocket costs and/or have access to care at facilities at your worksite. Please sign into MyBenefits for more details. * Based on internal analysis by MetLife. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often members visit participating dentists and the cost of services rendered. Negotiated fees are subject to change.

How do I find a participating dentist?

There are thousands of general dentists and specialists to choose from nationwide --so you are sure to find one that meets your needs. You can receive a list of these participating dentists online at www.metlife.com/dental or call 1-800-275-4638 to have a list faxed or mailed to you.

What services are covered by my plan?

All services defined under your group dental benefits plan are covered. Please review the enclosed plan benefits summary to learn more.* *The information in this document represents an overview of your plan benefits, but is not a complete description of the plan. Before making any purchase or enrollment decision you should review the certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this overview and your certificate of insurance, your certificate of insurance governs.

May I choose a non-participating dentist?

Yes. You are always free to select the dentist of your choice. However, if you choose a non-participating (out-of-network) dentist, your out-of-pocket costs may be higher.

Can my dentist apply for participation in the network?

Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application.* The website and phone number are for use by dental professionals only. * Due to contractual requirements, MetLife is prevented from soliciting certain providers.

How are claims processed?

Dentists may submit your claims for you which means you have little or no paperwork. You can track your claims online and even receive email alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/dental or request one by calling 1-800-275-4638.

Can I get an estimate of what my out-of-pocket expenses will be before receiving a service?

Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the office.

Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

Can MetLife help me find a dentist outside of the U.S. if I am traveling?

Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1-312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. Coverage will be considered under your out-of-network benefits.** Please remember to hold on to all receipts to submit a dental claim. *International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. (AXA Assistance). AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits provided by MetLife. Referral services are not available in all locations. ** Refer to your dental benefits plan summary for your out-of-network dental coverage.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 49

How does MetLife coordinate benefits with other insurance plans?

Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions requires MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan.

Do I need an ID card?

No, You do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are enrolled in a MetLife Dental Plan. Your dentist can easily verify information about your coverage through a toll-free automated Computer Voice Response system.

Do my dependents have to visit the same dentist that I select?

No. You and your dependents each have the freedom to choose any dentist.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ŠUnited Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 50

CALIFORNIA IillALTIICARE LANGUA GE ASSISTANCE PROGRJ\.M NOTICE TO INSUREDS No Cost Language Services. You can get an interpreter. You can gel documents read to you and some sent to you in your language. For hap, call us at the number listed on your ID card, if any, or 1-800-942-0854. For more help call theCA Deplof Insurance at1-800-927-4357.

To receive a copy of the aHached Metlife document translated into Spanish or Chinese, ease mark the box by the requestedlanguage statement below,and mail the document with this form to: Metropolitan Life Insurance Company POBox 14587 Lexington, KY 40512 Please incicate to whom and wher e the translated doc ument is to be sent D Servicio de Idiomas Sin Casto. Puede obtener Ia ayuda de un interprete. Se le pueden leer documentos y enVlar algunos en espaiict. Para recibir ayuda,

llamenos aJ numero que aparece en sutaeta de identificaci6n,si tiene una, o ai1-800-942-D854.Para recibir ayuda adiciooalllame aJ Departamento de Seguros de California 811-800-927-4357.

Para recibir una copia del documenta adjunto de Metlife traducido al espana,marque Ia casilla correspondiente a esta oraci6n,y envie par correo el documento junto con este formtjario a: Metropolitan Life Insurance Company PO Box 14587 Lexington,KY 40512 Por favor,incique a quien y a d6nde debe enviarse a documento traducido.

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CA LAP STANDALONE NOTICE

September 2008

ASPEN 2018 BENEFITS :: 51

Dental

Plan Design for: BRG Management Inc dba Aspen Heights Date Prepared: February 28, 2017 The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a healthier smile and a healthier you.

Coverage Type: Type A - Preventive Type B - Basic Restorative Type C - Major Restorative Type D - Orthodontia

In-Network1 % of PDP Fee 100% 80% 50% 50%

2

Out-of-Network1 % of R&C Fee4 100% 80% 50% 50%

Deductible3 Individual Family

$50 $150

$50 $150

$1750

$1750

Annual Maximum Benefit: Per Individual Orthodontia Lifetime Maximum Ortho applies to Adult and Child

1.

2.

3.

4.

Up to dependent age limit $1500 per Person $1500 per Person

"In-Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist.

Negotiated fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

Applies to Type B and C services only.

Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of: · the dentist’s actual charge (the 'Actual Charge'), · the dentist’s usual charge for the same or similar services (the 'Usual Charge') or · the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the 'Customary Charge'). For your plan, the Customary Charge is based on the 90th percentile. Services must be necessary in terms of generally accepted dental standards.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 52

Selected Covered Services and Frequency Limitations* Type A - Preventive Y4

Oral Examinations Full Mouth X-rays Bitewing X-rays (Adult/Child) Prophylaxis - Cleanings Topical Fluoride Applications Sealants Space Maintainers Emergency Palliative Treatment Harmful Habits Appliances

How Many/How Often: 1 in 6 months 1 in 60 months 1 in 12 months 1 in 6 months 2 in 12 months - Children to age 14 1 in 36 months - Children to age 16 1 per lifetime per tooth area - Children up to age 16

Type B - Basic Restorative Amalgam and Composite Fillings Prefabricated Crowns Endodontics Root Canal Periodontal Surgery Periodontal Scaling & Root Planing Periodontal Maintenance Oral Surgery (Simple Extractions) Oral Surgery (Surgical Extractions) Other Oral Surgery General Anesthesia Consultations

How Many/How Often: 1 in 24 months. All teeth 1 per tooth in 24 months 1 per tooth per lifetime 1 in 36 months per quadrant 1 in 24 months per quadrant 2 in 1 year, includes 2 cleanings

1 in 12 months

Type C - Major Restorative Crowns/Inlays/Onlays Repairs Bridges Dentures Implant Services TMJ

How Many/How Often: 1 per tooth in 10 years 1 in 12 months 1 in 10 years 1 in 10 years 1 service per tooth in 10 years - 1 repair per 10 years Major Service as part of Annual Maximum.

Type D – Orthodontia · · ·

·

Adult and Child Coverage. Dependent children up to age 26. Age limitations may vary by state. Please see your Plan description for complete details. In the event of a conflict with this summary, the terms of the certificate will govern.

All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.

Benefits for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for Orthodontia. Periodic follow-up visits will be payable on a monthly basis during the scheduled course of the orthodontic treatment. Allowable expenses for the initial placement, periodic follow-up visits and procedures performed in connection with the orthodontic treatment, are all subject to the Orthodontia coinsurance level and Lifetime Maximum Benefit Amount as defined in the Plan Summary.

Orthodontic benefits end at cancellation of coverage

*Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you receive a more costly treatment alternative, your dentist may charge you or your dependent for the difference between the cost of the service that was performed and the least costly treatment alternative.

The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 53

We will not pay Dental Insurance benefits for charges incurred for: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature; Services for which You would not be required to pay in the absence of Dental Insurance; Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate).

Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: · scaling and polishing of teeth; or · fluoride treatments.

For NY Sitused Groups, this exclusion does not apply.

Services or appliances which restore or alter occlusion or vertical dimension.

Restoration of tooth structure damaged by attrition, abrasion or erosion.

Restorations or appliances used for the purpose of periodontal splinting.

Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.

Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.

Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.

Missed appointments.

Services · covered under any workers’ compensation or occupational disease law; · covered under any employer liability law; · for which the employer of the person receiving such services is not required to pay; or · received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

For North Carolina and Virginia Sitused Groups, this exclusion does not apply.

Services paid under any worker’s compensation, occupational disease or employer liability law as follows: · for persons who are covered in North Carolina for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act; · or for persons who are not covered in North Carolina, services paid or payable under any workers compensation or occupational disease law.

This exclusion only applies for North Carolina Sitused Groups.

Services: · for which the employer of the person receiving such services is not required to pay; or · received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

This exclusion only applies for North Carolina Sitused Groups.

Services covered under any workers' compensation, occupational disease or employer liability law for which the employee/or Dependent received benefits under that law.

This exclusion only applies for Virginia Sitused Groups.

Services: · for which the employer of the person receiving such services is not required to pay; or · received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital.

This exclusion only applies for Virginia Sitused Groups.

Services covered under other coverage provided by the Employer.

Temporary or provisional restorations.

Temporary or provisional appliances.

Prescription drugs.

Services for which the submitted documentation indicates a poor prognosis.

The following when charged by the Dentist on a separate basis: · claim form completion; · infection control such as gloves, masks, and sterilization of supplies; or · local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.

Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food.

For NY Sitused Groups, this exclusion does not apply.

Caries susceptibility tests.

Other fixed Denture prosthetic services not described elsewhere in this certificate.

Precision attachments, except when the precision attachment is related to implant prosthetics.

Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it.

Repair or replacement of an orthodontic device.1 Duplicate prosthetic devices or appliances.

Replacement of a lost or stolen appliance, Cast Restoration, or Denture.

Intra and extraoral photographic images.

Services or supplies furnished as a result of a referral prohibited by Section 1-302 of the Maryland Health Occupations Article.

A prohibited referral is one in which a Health Care Practitioner refers You to a Health Care Entity in which the Health Care Practitioner or Health Care Practitioner’s immediate family or both own a Beneficial Interest or have a Compensation Agreement. For the purposes of this exclusion, the terms “Referral”, “Health Care Practitioner” , “Health Care Entity”,

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 54

“Beneficial Interest” and Compensation Agreement have the same meaning as provided in Section 1-301 of the Maryland Health Occupations Article.

This exclusion only applies for Maryland Sitused Groups 1Some

of these exclusions may not apply. Please see your plan design and certificate for details.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 55

Common Questions … Important Answers Who is a participating dentist?

A participating, or network, dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in full for covered services provided to plan members, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees typically range from 15-45% below the average fees charged in a dentist’s community for the same or substantially similar services.* In addition to the standard MetLife network, your employer may provide you with access to a select network of dental providers that may be unique to your employer’s dental program. When visiting these providers, you may receive a better benefit, have lower out-of-pocket costs and/or have access to care at facilities at your worksite. Please sign into MyBenefits for more details. * Based on internal analysis by MetLife. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often members visit participating dentists and the cost of services rendered. Negotiated fees are subject to change.

How do I find a participating dentist?

There are thousands of general dentists and specialists to choose from nationwide --so you are sure to find one that meets your needs. You can receive a list of these participating dentists online at www.metlife.com/dental or call 1-800-275-4638 to have a list faxed or mailed to you.

What services are covered by my plan?

All services defined under your group dental benefits plan are covered. Please review the enclosed plan benefits summary to learn more.* *The information in this document represents an overview of your plan benefits, but is not a complete description of the plan. Before making any purchase or enrollment decision you should review the certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this overview and your certificate of insurance, your certificate of insurance governs.

May I choose a non-participating dentist?

Yes. You are always free to select the dentist of your choice. However, if you choose a non-participating (out-of-network) dentist, your out-of-pocket costs may be higher.

Can my dentist apply for participation in the network?

Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application.* The website and phone number are for use by dental professionals only. * Due to contractual requirements, MetLife is prevented from soliciting certain providers.

How are claims processed?

Dentists may submit your claims for you which means you have little or no paperwork. You can track your claims online and even receive email alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/dental or request one by calling 1-800-275-4638.

Can I get an estimate of what my out-of-pocket expenses will be before receiving a service?

Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the office.

Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

Can MetLife help me find a dentist outside of the U.S. if I am traveling?

Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1-312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. Coverage will be considered under your out-of-network benefits.** Please remember to hold on to all receipts to submit a dental claim. *International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. (AXA Assistance). AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits provided by MetLife. Referral services are not available in all locations. ** Refer to your dental benefits plan summary for your out-of-network dental coverage.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 56

How does MetLife coordinate benefits with other insurance plans?

Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions requires MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan.

Do I need an ID card?

No, You do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are enrolled in a MetLife Dental Plan. Your dentist can easily verify information about your coverage through a toll-free automated Computer Voice Response system.

Do my dependents have to visit the same dentist that I select?

No. You and your dependents each have the freedom to choose any dentist.

Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ŠUnited Feature Syndicate, Inc.

ASPEN 2018 BENEFITS L0916478823[exp0218][All States] :: 57

CALIFORNIA IillALTIICARE LANGUA GE ASSISTANCE PROGRJ\.M NOTICE TO INSUREDS No Cost Language Services. You can get an interpreter. You can gel documents read to you and some sent to you in your language. For hap, call us at the number listed on your ID card, if any, or 1-800-942-0854. For more help call theCA Deplof Insurance at1-800-927-4357.

To receive a copy of the aHached Metlife document translated into Spanish or Chinese, ease mark the box by the requestedlanguage statement below,and mail the document with this form to: Metropolitan Life Insurance Company POBox 14587 Lexington, KY 40512 Please incicate to whom and wher e the translated doc ument is to be sent D Servicio de Idiomas Sin Casto. Puede obtener Ia ayuda de un interprete. Se le pueden leer documentos y enVlar algunos en espaiict. Para recibir ayuda,

llamenos aJ numero que aparece en sutaeta de identificaci6n,si tiene una, o ai1-800-942-D854.Para recibir ayuda adiciooalllame aJ Departamento de Seguros de California 811-800-927-4357.

Para recibir una copia del documenta adjunto de Metlife traducido al espana,marque Ia casilla correspondiente a esta oraci6n,y envie par correo el documento junto con este formtjario a: Metropolitan Life Insurance Company PO Box 14587 Lexington,KY 40512 Por favor,incique a quien y a d6nde debe enviarse a documento traducido.

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CA LAP STANDALONE NOTICE

September 2008

ASPEN 2018 BENEFITS :: 58

With your Vision Preferred Provider Organization Plan, you can: xGo to any licensed vision specialist and receive coverage. Just remember your benefit dollars go further when you stay in network. xChoose from a large network of ophthalmologists, optometrists and opticians, from private practices to ® retailers like Costco Optical and Visionworks. x Take advantage of our service agreement with Walmart and Sam's Club—they check your eligibility and process claims even though they are out of network.

In-network value added features: Additional lens enhancements:1 Average 20-25% savings on all other lens enhancements.

Savings on glasses and sunglasses: Get 20% savings on additional pairs of prescription glasses and nonprescription sunglasses, including lens enhancements. At times, other promotional offers may also be available.

Laser vision correction: 2 Savings averaging 15% off the regular price or 5% off a promotional offer for laser surgery including PRK, LASIK and Custom LASIK. This offer is only available at MetLife participating locations.

In-network benefits There are no claims for you to file when you go to a participating vision specialist.

Simply pay your copay and, if applicable, any amount over your allowance at the time of service.

Frequency

Eye exam

Once every 12 months

x Eye health exam, dilation, prescription and refraction for glasses: Covered in full after a $10 copay. x Retinal imaging:1 Up to a $39 copay on routine retinal screening when performed by a private practice provider.

Frame

Once every 24 months

x Allowance: $130 after $25 eyewear copay x Costco: $70 allowance after $25 eyewear copay You will receive an additional 20% savings on the amount that you pay over your allowance. This offer is available from all participating locations except Costco.1

Standard corrective lenses

Once every 12 months

x Single vision, lined bifocal, lined trifocal, lenticular: Covered in full after $25 eyewear copay.

Standard lens eQhancements1

Once every 12 months

x Polycarbonate (child up to age 18) and Ultraviolet (UV) coating: Covered in full after $25 eyewear copay. x Progressive, Polycarbonate (adult), Photochromic, Anti-reflective and Scratch-resistant coatings and Tints: Your cost will be limited to a copay that MetLife has negotiated for you. These copays can be viewed after enrollment at www.metlife.com/mybenefits.

Contact lenses (instead of eye glasses)

Once every 12 months

x Contact fitting and evaluation:1 Covered in full with a maximum copay of $60. x Elective lenses: $130 allowance x Necessary lenses: Covered in full after $25 eyewear copay

We’re here to help Find a participating vision specialist: www.metlife.com/mybenefits or call 1-855-MET-EYE1 (1-855-638-3931) Get a claim form: www.metlife.com/mybenefits General questions: www.metlife.com/mybenefits or call 1-855-MET-EYE1 (1-855-638-3931)

ASPEN 2018 BENEFITS :: 59

Out-of-network reimbursement You pay for services and then submit a claim for reimbursement. The same benefit frequencies for In-network benefits apply.

Once you enroll, visit www.metlife.com/mybenefits for detailed out-of-network benefits information. â&#x20AC;˘ Eye exam: up to $45

â&#x20AC;˘ Single vision lenses: up to $30

â&#x20AC;˘ Lined trifocal lenses: up to $65

â&#x20AC;˘ Frames: up to $70

â&#x20AC;˘ Lined bifocal lenses: up to $50

â&#x20AC;˘ Progressive lenses: up to $50

â&#x20AC;˘ Contact lenses: - Elective up to $105 - Necessary up to $210

â&#x20AC;˘ Lenticular lenses: up to $100

Exclusions and Limitations of Benefits This plan does not cover the following services, materials and treatments.

Services and Eyewear

xServices and/or materials not specifically included in the Vision Plan Benefits Overview (Schedule of Benefits). xAny portion of a charge above the Maximum Benefit Allowance or reimbursement indicated in the Schedule of Benefits. xAny eye examination or corrective eyewear required as a condition of employment. xServices and supplies received by you or your Dependent before the Vision Insurance starts. xMissed appointments. xServices or materials resulting from or in the course of a Covered Personâ&#x20AC;&#x2122;s regular occupation for pay or profit for which the Covered Person is entitled to benefits under any Workersâ&#x20AC;&#x2122; Compensation Law, Employerâ&#x20AC;&#x2122;s Liability Law or similar law.

You must promptly claim and notify the Company of all such benefits. xLocal, state and/or federal taxes, except where MetLife is required by law to pay. xServices or materials received as a result of disease, defect, or injury due to war or an act of war (declared or undeclared), taking part

1 All lens enhancements are available at participating private practices. Maximum copays and pricing are subject to change without notice. Please check with your provider for details and copays applicable to your lens choice. Please contact your local Costco to confirm the availability of lens enhancements and pricing prior to receiving services. Additional discounts may not be available in certain states.

2 Custom LASIK coverage only available using wavefront technology with the microkeratome surgical device. Other LASIK procedures may be performed at an additional cost to the member. Additional savings on laser vision care is only available at participating locations.

in a riot or insurrection, or committing or attempting to commit a felony. xServices and materials obtained while outside the United States, except for emergency vision care. xServices, procedures, or materials for which a charge would not have been made in the absence of insurance. xServices: (a) for which the employer of the person receiving such services is not required to pay; or (b) received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. xServices, to the extent such services, or benefits for such services, are available under a Government Plan. This exclusion will apply whether or not the person receiving the services is enrolled for the Government Plan.

We will not exclude payment of benefits for such services if the Government Plan requires that Vision Insurance under the Group Policy be paid first. Government Plan means any plan, program, or coverage which is established under the laws or regulations of any government. The term does not include any plan, program, or coverage provided by a government as an employer or Medicare. xPlano lenses (lenses with refractive correction of less than Âą .50 diopter). xTwo pairs of glasses instead of bifocals. xReplacement of lenses, frames and/or contact lenses furnished under this Plan which are lost, stolen, or damaged (within the 12 month benefit period from date of purchase.)

xContact lens insurance policies and service agreements. xRefitting of contact lenses after the initial (90-day) fitting period. xContact lens modification, polishing, and cleaning. xThe following items are not covered under the covered contact lenses enhancement: Corneal Refractive Therapy (CRT) or Orthokeratology (a procedure using contact lenses to change the shape of the cornea in order to reduce myopia); replacement of lost or damaged lenses; insurance policies or service agreements; plano lenses (i.e., when patientâ&#x20AC;&#x2122;s refractive error is less than a +/0.50 diopter power); plano lenses to change eye color cosmetically; artistically painted lenses; additional office visits associated with contact lens pathology; contact lens modification, polishing or cleaning; and refitting after the initial (90-day) fitting period.

Treatments

xOrthoptics or vision training and any associated supplemental testing. xMedical and surgical treatment of the eye(s).

Medications xPrescription and non-prescription medication

Important: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family.

M130D-10/25 Benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. Certain claims and network administration services are provided through Vision Service Plan. In certain states, availability of MetLifeâ&#x20AC;&#x2122;s group vision benefits is subject to regulatory approval. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details.

Metropolitan Life Insurance Company, New York, NY 10166 Š 2014 METLIFE, INC. / >H[S @>$OO 6WDWHV@

ASPEN 2018 BENEFITS :: 60

Liberty Mutual Insurance

Aspen Heights Summary of Benefits Short-Term Disability Insurance

Group disability insurance offers income protection Disability is often called the “forgotten risk,” as few employees think about how they would survive financially with no earned income. The impact of a disabling illness or injury, both financially and emotionally, is devastating.

While health insurance may cover most medical bills, daily living expenses such as rent or mortgage, car payments, and utilities continue. Short-term disability insurance provides partial income replacement if you are unable to work due to a qualifying non-occupational illness or injury for periods ranging from a few days to several weeks.

Eligibility

All full-time employees working a minimum of 30 regularly scheduled hours per week.

Waiting Period

You are eligible on the first of the month coincident with or next following date of hire.

Benefit

STD coverage is employer-paid. If you become disabled (as defined in the plan) and remain disabled through the elimination period, the plan benefit pays 60% of your weekly earnings, less other deductible sources of income, such as statemandated benefits and sick pay (see your plan booklet for details). The maximum weekly benefit is $2,000.

Elimination Period

Benefits are payable after a period of fourteen calendar days due to injury or sickness.

Maximum Duration

Short-term disability benefits will end at either the end of the disability or the end of the 13th week of disability, whichever comes first.

Definition of Disability

You will be considered disabled if you are unable to perform the duties of your “own job.” Refer to your certificate of coverage for definitions of “own job” and “any job.”

Partial Disability Benefits

Partial disability benefits can be payable if your earnings are between 20% and 80% of your pre-disability earnings.

Successive Disability

If you become disabled for the same condition within 14 days following your prior disability, your benefits will continue under the same claim.

Please Note: Taxability will vary based on election and employer and employee contributions. Pre-existing condition exclusions may affect the payment of benefits. Please see your Human Resources department or Benefits department for additional information.

Online solutions to manage your benefits MyLibertyConnection® offers secure access to online resources and tools to help you better understand and manage your benefits. You can:    

Report an absence or track the status of an existing absence Review claim payment information Complete a statement of health (Evidence of Insurability) application Add or change beneficiary designations

This brochure is a general description of coverage and/or services offered. See your policy or service contract for actual terms and conditions.

Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA. © 2017 Liberty Mutual Insurance, 175 Berkeley Street, Boston, MA 02116.

ASPEN 2018 BENEFITS :: 61

Liberty Mutual Insurance

Aspen Heights Summary of Benefits Long-Term Disability Insurance

Group disability insurance offers income protection Disability is often called the “forgotten risk,” as few employees think about how they would survive financially with no earned income. The impact of a disabling illness or injury, both financially and emotionally, is devastating.

While health insurance may cover most medical bills, daily living expenses such as rent or mortgage, car payments, and utilities continue. Disability insurance provides partial income replacement if you are unable to work due to a qualifying illness or injury. An employee generally begins with what is considered a short-term disability for a period of 13 weeks. If the illness or injury extends beyond that period it becomes long-term disability.

Eligibility

All full-time employees working a minimum of 30 regularly scheduled hours per week.

Waiting Period

You are eligible on the first of the month coincident with or next following date of hire.

Benefit

Voluntary LTD is paid for by you. If you purchase this coverage, become disabled (as defined in the plan), and remain disabled through the elimination period, you will receive 60% of your monthly covered earnings, less other deductible sources of income, such as Social Security and workers compensation (see your plan booklet for details). The maximum monthly benefit is $7,500.

Elimination Period

Benefits are payable after a period of 90 consecutive days of disability.

Definition of Disability

You will be considered disabled if, during the elimination period and the next 24 months of disability, you are unable to perform the duties of your “own occupation” and thereafter, you are unable to perform the duties of “any occupation.” Refer to your certificate of coverage for definitions of “own occupation” and “any occupation.”

Age at Disability

Maximum Benefit Period

Maximum Benefit Period

Less than age 60--------------------- Greater of SSNRA* or to age 65 (but not less than 5 years) 60 -------------------------------------- 60 months 61 -------------------------------------- 48 months 62 -------------------------------------- 42 months 63 -------------------------------------- 36 months 64 -------------------------------------- 30 months 65 -------------------------------------- 24 months 66 -------------------------------------- 21 months 67 -------------------------------------- 18 months 68 -------------------------------------- 15 months 69 and over -------------------------- 12 months *SSNRA means the Social Security Normal Retirement Age as figured by the 1983 amendment to the Social Security Act and any subsequent amendments.

This brochure is a general description of coverage and/or services offered. See your policy or service contract for actual terms and conditions.

Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA. © 2017 Liberty Mutual Insurance, 175 Berkeley Street, Boston, MA 02116.

ASPEN 2018 BENEFITS :: 62

Liberty Mutual Insurance

Year of Birth Before 1938 ------------------------1938 ----------------------------------1939 ----------------------------------1940 ----------------------------------1941 ----------------------------------1942 ----------------------------------1943-1954 --------------------------1955 ----------------------------------1956 ----------------------------------1957 ----------------------------------1958 ----------------------------------1959 ----------------------------------1960 and after ----------------------

Normal Retirement Age 65 65 and 2 months 65 and 4 months 65 and 6 months 65 and 8 months 65 and 10 months 66 66 and 2 months 66 and 4 months 66 and 6 months 66 and 8 months 66 and 10 months 67

Successive Disability

If you become disabled for the same condition within six months following your prior disability, your benefits will continue under the same claim.

Survivor Benefit

A lump-sum payment, equal to three months of benefits paid, to an eligible survivor or estate if you are receiving a benefit and have been disabled for at least 180 days.

MyLibertyAssist®

As an employee covered under your employer’s group long-term disability policy issued by Liberty Life Assurance Company of Boston, you are eligible for MyLibertyAssist Employee Assistance Program (EAP). These benefits include financial, legal, and family services and are available to you and your immediate family members. Employee Assistance Program (“Services”) available under MyLibertyAssist are provided by Morneau Shepell. Liberty Life Assurance Company of Boston does not insure or administer these services.

Please Note: Taxability will vary based on election and employer and employee contributions. Evidence of Insurability may be required. Pre-existing condition exclusions may affect the payment of benefits. Please see your Human Resources Department or Benefits Department for additional information.

This brochure is a general description of coverage and/or services offered. See your policy or service contract for actual terms and conditions.

Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA. © 2017 Liberty Mutual Insurance, 175 Berkeley Street, Boston, MA 02116.

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Liberty Mutual Insurance

Aspen Heights Summary of Benefits Life and AD&D Insurance

Group life insurance coverage can offer important financial protection Most people agree that protecting their loved ones in the event of death is very important. Consider what would happen to your dependents if they no longer had your income to rely on. Life insurance can help your family maintain its standard of living as well as secure plans for college and retirement. With the right amount of life insurance, you’ll know that your family’s financial obligations will be covered.

Together with your employer, Liberty Mutual Insurance* offers you an opportunity to purchase Optional Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance for you and your dependents.

Eligibility

All full-time employees working a minimum of 30 regularly scheduled hours per week.

Waiting Period

You are eligible on the first of the month coincident with or next following date of hire.

Employee Benefit

Employee Basic Term Life and AD&D: Coverage is equal to one times your base annual salary1 rounded up to the next $1,000. This amount may not exceed $50,000.2 Coverage is employer-paid.

Employee Optional Term Life and AD&D: You may purchase increments of $10,000 not to exceed the lesser of five times your base annual salary or $500,000.2

Dependent Spouse Benefit

Optional Dependent Spouse Life and AD&D: You may purchase increments of $5,000 to a maximum $250,000. The amount of Dependent Life and AD&D Insurance coverage cannot be greater than 50 percent of the Employee Benefit.2

Dependent Child Benefit

Optional Dependent Child Life and AD&D: Child coverage is equal to: $5,000 or $10,000 if under age 26 years.

Evidence of Insurability

Employee: A health statement is required if the amount of the increase is lesser of five times your annual earnings or greater than $150,000 or any increase at each annual enrollment.

Spouse: A health statement is required if the amount of the increase is greater than $50,000 or any increase at each annual enrollment.

Conversion/Portability

Conversion: If all or part of your basic, optional and dependent life coverage ends, you may convert the amount that ends to an individual life insurance policy without medical evidence.

Portability: If all or part of your basic, optional and optional dependent life coverage ends, you may continue all or part of the amount that ends, less any

* Liberty Mutual Insurance (“Liberty Mutual”) is the marketing brand for Liberty Mutual Group and its related subsidiaries.

1

For the definition of your base annual salary, please see your plan booklet or contact your Human Resources department.

The Employee Benefit is equal to the combined amount of the Basic Term Life and Optional Term Life coverage.

2

This brochure is a general description of coverage and/or services offered. See your policy or service contract for actual terms and conditions.

Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA. © 2017 Liberty Mutual Insurance, 175 Berkeley Street, Boston, MA 02116.

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Liberty Mutual Insurance

amounts converted to an individual policy. Portable group term life insurance is not available if coverage ends because the policy terminates.

Waiver of Premium

Included with employer policy

Reduction Schedule

When you reach age 65, life benefits reduce to 65%. When you reach age 70, life benefits reduce to 40%. When you reach age 75, life benefits reduce to 25%.

MyLibertyAssist

As an employee covered under your employer’s group life policy issued by Liberty Life Assurance Company of Boston, you are eligible for MyLibertyAssist Employee Assistance Program (EAP). These benefits include financial, legal, and family services and are available to you and your immediate family members. Employee Assistance Program (“Services”) available under MyLibertyAssist are provided by Morneau Shepell. Liberty Life Assurance Company of Boston does not insure or administer these services.

Travel Assistance

Travel Assistance provides 24/7/365 access to pre-travel, personal, and emergency help with situations that may arise during travel. Services are available to the covered employee while on business or personal travel more than 100 miles from home and for fewer than 90 consecutive travel days. Dependents traveling with the employee are also covered. Travel assistance services are administered by UnitedHealthcare Global. UnitedHealthcare Global must make all arrangements for Liberty to cover costs of covered events.

Accidental Death & Dismemberment insurance provides a benefit when an injury resulting from an accident causes the death or other covered losses to the insured.

Please Note: Evidence of insurability may be required. Please see your Human Resources department or Benefits department for additional information.

The above information provides highlights of the insurance program. It does not and is not intended to cover the program in detail. Please refer to the policy for a complete description of the coverage, limitations, and exclusions.

This brochure is a general description of coverage and/or services offered. See your policy or service contract for actual terms and conditions.

Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA. © 2017 Liberty Mutual Insurance, 175 Berkeley Street, Boston, MA 02116.

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MyLibertyAssist

Liberty Mutual Insurance GROUP BENEFITS

®

Employee Assistance Program (EAP)

Liberty Mutual Insurance* is pleased to offer an EAP through an arrangement with Morneau Shepell.

As an employee covered under your employer’s group long-term disability and/or life policy from Liberty Mutual, you are eligible for MyLibertyAssist, an EAP provided by Morneau Shepell.

MyLibertyAssist: EAP

MyLibertyAssist EAP services are available to you and your immediate family members.

Services Face-to-face sessions1,2,3

Financial

Legal

Family

Assistance from financial counselors: ■■ Address financial concerns ■■ Request educa­ tional material

Assistance from attorneys: ■■ Free 30-minute telephonic or faceto-face session ■■ Up to 25% employee discount on additional services

Assistance from work-life specialists and care consultants: ■■ Free telephonic session ■■ Online access to information and provider locators

Assistance with: ■■ Document preparation ■■ Divorce and separation ■■ Real estate ■■ Civil matters

Assistance with: ■■ Child care ■■ Elder care ■■ Adoption ■■ Education

Telephonic assistance: ■■ Unlimited 24/7/365 telephonic assessments Financial advice sessions: ■■ Text ■■ One free telephonic ■■ Live chat via website session and financial worksheet review Assistance with: ■■

■■

■■ ■■

■■

Marital and family concerns Stress and anxiety management Depression Alcohol and drug abuse Grief and loss

Also available: ■■ Resource center for daily living discounts ■■ Better Living wellness portal

Assistance with: ■■ Financial Planning ■■ Credit and Debt Management ■■ Real Estate/ Mortgage Information

Care consultant assistance with: ■■ Apartment locators ■■ Home repair contractors ■■ Pet care and training ■■ Transportation and travel

1 In California, sessions are limited to three (3) in a six-month period, not to exceed a total of five (5) sessions per year.

2 Covered individuals are eligible for a combined total of five (5) face-to-face sessions with Morneau Shepell clinicians.

Individual face-to-face sessions are available for covered individuals 16 years and older. Family/group face-to-face sessions are available for covered individuals 12 years and older, and their parents. Face-to-face sessions are not available to children under the age of 12.

3 Covered individuals with complex and/or longer-term problems will be referred by your Morneau Shepell clinician to another professionally trained clinician. This referral will be billed to your health insurance plan or a community provider and does not count toward your five (5) grief and/or legal sessions. * Liberty Mutual Insurance (“Liberty Mutual”) is the marketing brand for Liberty Mutual Group and its related subsidiaries.

Group insurance products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company.

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MyLibertyAssist EAP: Web Services The MyLibertyAssist website is user-friendly and offers practical EAP-related information that addresses emotional well-being, health and wellness, and daily living concerns. Resources available include interactive self-assessments, a comprehensive library of articles and guides, and financial calculators.

The website provides employees and their immediate family members with the information they need and is conveniently organized in the following categories:

Financial Security: Achieve financial well-being with a better understanding of financial matters. Read articles to help address financial and legal questions, such as debt, investments, retirement, taxes, bankruptcy, wills and estate planning, and identity theft. State-specific legal forms and documents are available for personal use and can be stored on a secure server.

Financial calculators are also available for the following topics: ■■ ■■

Health and Well-Being: Improve your physical and mental well-being with helpful health information. Utilize self-help tools, self-assessments, and information on emotional resilience, self-esteem, grief and bereavement, as well as guidance on how to access help for conditions such as anxiety, depression, and addiction.

Career and Workplace: Access tools to help you manage your career, better handle workplace relationships, and find work-life balance. Resources include employee and supervisor work performance toolboxes with articles, and information to help develop workplace and leadership skills. Information on managing work-related issues such as conflict and communication is also available.

■■ ■■ ■■

Mortgage Loan Auto Credit cards and debt management Retirement saving

Life Events: Find useful information to better inform and support you during life events and times of change. Resources are available to help address responsibilities and issues concerning the family, such as pregnancy, child care, parenting, child and adolescent development, and elder care. This site also includes a locator that allows users to search for child and elder care options.

To access MyLibertyAssist EAP Online: workhealthlife.com/mlassist Telephone: 877-695-2789

libertymutualgroup.com/business

@LibertyB2B

Employee Assistance Program (“Services”) available under MyLibertyAssist® are provided by Morneau Shepell. Liberty Life Assurance Company of Boston does not insure or administer these Services. Group products and services are offered by Liberty Life Assurance Company of Boston, a Liberty Mutual company. Home Office: Boston, MA. © 2017 Liberty Mutual Insurance. LMB 503 09/17

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Liberty Mutual Insurance Group Benefits

Life Services Website An Employee Guide

Funeral planning | Identity theft | Grief & loss | Wellness | Legal & financial

Liberty Mutual Insurance is proud to offer an educational life services website with valuable information on funeral planning, identity theft, grief and loss, wellness, legal and financial planning, and online will preparation.

Our life services website offers easy-tounderstand information on topics of concern for you and your dependents.1 Life service’s five areas of focus include:

Grief and loss

Funeral planning

• Information about grief, including the stages of grief, how to cope with grief, and ways to help others through the process

• A planning questionnaire and guide to outline different options when planning services • A calculator to estimate funeral costs • A locator to assist in finding funeral homes, cemeteries, and funeral service providers

• Guidance on how to cope with death—from saying good-bye to addressing legal and financial matters

• Tips and techniques to support individuals experiencing post-traumatic stress disorder

Wellness

• Guidance on activities such as obtaining a death certificate and writing an obituary

• Tips on healthy eating and weight management

• Information on funeral customs of different religions or cultures

• Guidance on exercise—from choosing a gym to assessing different types of workouts

Identity theft

• A comprehensive library of articles on emotional resilience and stress reduction and management

• Tips on how to prevent identity theft by protecting passwords and personal records • A risk calculator to develop a personalized assessment of an individual’s risk • A recovery kit with step-by-step instructions on what to do after becoming a victim • Forms needed to resolve identity theft–related issues

Legal and financial • Learn more about real estate, such as buying and selling a home • Review resources on family and elder care • Access a variety of calculators to help determine mortgage payments, manage credit card debt, and save for college or retirement • Create a legally binding will and legal documents online that can be revised, downloaded, and printed at any time

The life services website can be accessed by visiting www.BDAlifeservices.com

Username: MLLIFE Life services is available to employees and dependents covered by group life insurance programs issued by Liberty Life Assurance Company of Boston. Life services is provided by Bensinger, DuPont & Associates. Liberty Life Assurance Company of Boston does not administer these services.

1

© 2013 Liberty Mutual Group. All Rights Reserved. GRP 118 2/13

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Tango Health Savings Account (HSA) FAQs & How To’s If you are unfamiliar with how a Health Savings Account works, watch this short video: http://www.tangohealth.com/health-savings-account-101/ I have included the answers to Frequently Asked Questions below. If you have further questions, please contact the really awesome Customer Support Team at Tango: - Call toll-free at (866) 384-8549 - E-mail a question to support@tangohealth.com - Submit a ticket or search our forums at https://support.tangohealth.com NOTE: You can set up deductions from your paycheck in Tango (not in ADP). Any changes to payroll deductions in Tango will need to be made at least 6 business days before the payroll check date to take effect during the same pay period.

You should receive your HSA debit card by mail at your mailing address within 12 business days of when you log in to activate your account. Please let me know if you have any questions or if you don't receive your card.

To set up your HSA payroll deduction in Tango’s HSA Management Website: 1. Log in to Tango at https://hsa.tangohealth.com/t/a/login/launch 2. Click “Update Payroll Deduction” in the middle box To upload receipts for your HSA purchases in Tango’s HSA Management Website: 1. Log in to Tango at https://hsa.tangohealth.com/t/a/login/launch 2. Click “ Record & Review Expenses” in the middle box 3. You need to upload itemized receipts for all qualifying medical expenses, both those paid with your HSA Debit Card AND those paid for with cash/check/credit card. If you are ever audited you need to be able to show that these funds were only used on eligible expenses.

To Reimburse Yourself for Medical Expenses NOT Paid For With Your HSA Debit Card: 1. Log in to Tango at https://hsa.tangohealth.com/t/a/login/launch 2. Click “Pay Yourself Back” in the middle box 3. Don’t forget to still upload your receipts To see what expenses qualify as HSA Eligible Expenses, click here: https://support.tangohealth.com/hc/en-us/articles/203441644-Eligible-Expenses Your HSA card is a debit card so you can only spend what you have in the account. You will use the same debit card for the life of your account – don’t throw it away just because you’ve used all the current funds.

To check your balance, create an account at Optum Bank (if it is your first time click Register Now): https://secure.optumhealthfinancial.com/CAP/Portlets/login.jsf?OFSP_login=consumer

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To request a new Optum Bank HSA Debit Card: Contact Optum Bank at 866-234-8913. ** To set up your 2018 elections while weâ&#x20AC;&#x2122;re still in 2017: 1) Log in to Tango at hsa.tangohealth.com 2) Click "Update payroll Deduction" in the center of the screen 3) Click "Change Payroll Deduction" on the right part of the screen 4) At the very top left it will say "Calculate for" and then have a radio button for 2017 or 2018. Click on the one next to 2017.

5) Enter the per paycheck (AKA per pay period) amount that you want deducted (we have 24 pay periods per year). Example: if you want to contribute $2000 over the year, take $2000 divided by 24 pay periods = $83.34 per pay period.

6) Click "Next" at the bottom 7) Make sure it says "$xxx desired 01/01/2018" at the top of the page so you make sure you are changing it for 2017.

8) Click "Confirm Change Request"

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Aspen Heights 401k Information I have attached information regarding our 401k program (both traditional and ROTH are available). You will be eligible to contribute on the first day of your 7th month with Aspen Heights. To see your account in ADP (https://workforcenow.adp.com), go to Myself > Benefits > Retirement Savings.

Important Information:  Aspen’s employer match for 401k is up to 50% of the first 6 % you put in. To get the full 3% employer match you need to elect at least 6% via payroll deduction. The election can be over any combination of a regular and/or Roth 401k but the employer match will be deposited into a regular 401k account (not a Roth account). Example: you can elect 5% to your Roth IRA and 1% to your regular IRA and that will total the needed 6% to get the full 3% match.  On your 1 year anniversary of starting with Aspen Heights you will be 50% vested in your employer match and on your 2nd anniversary of starting with Aspen Heights you will be 100% vested in your employer match. Being vested means that you can take that portion of the employer match with you if you were to leave our company. You are always 100% vested in the money you contribute, but you have to wait until your vesting dates to get that amount of the employer match. Here is more information on what “vesting” means http://money.cnn.com/retirement/guide/401k_basics.moneymag/index10.htm .  Employees will be auto-enrolled in the 401k at 2% contribution on the first day of their 7th month from date of hire. You will want to go into your account (in ADP https://workforcenow.adp.com > Myself > Benefits > Retirement Savings) or contact the 401k help line (see number below) to raise your contribution rate to 6% and choose where you want that money invested.  Check out this article for more information on 401ks (for beginners): http://www.thesimpledollar.com/a-complete-beginners-guide-to-401k-plans/ For assistance enrolling, chosing your investments, or for any other questions, you can call the 401k Participant Help Line at 800-695-7526.

To Opt Out of our Plan: in ADP (https://workforcenow.adp.com) go to Myself > Benefits > Retirement Savings. Change your contribution percentage to 0% and click SAVE. Roll Overs Into Our Plan: If you are interested in rolling funds from a previous retirement program into ours please call the 401k Team to get the most up to date instructions (800-695-7526).

Also make sure to enter your beneficiaries in your 401k account online. Unfortunately the beneficiaries you enter in ADP for your life insurance do not transfer over to your 401k so you need to enter beneficiaries for your 401k plan. The beneficiaries you should enter are the people that you want your 401k to go to in the event of your death.

TO ADD BENEFICIARIES FOR YOUR 401K:  log in to the 401k website at www.mykplan.com  click My Account > Manage My Beneficiaries  click Add New Beneficiary

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 add your Primary Beneficiary (you can have more than one but the percentage needs to add to 100%)  add Secondary Beneficiaries (these would be who would get the money if your primary beneficiaries are no longer alive)  click SAVE after you have added your beneficiaries.

If you don’t have someone’s social security information, at least enter their names and all other information you do have.

Thank you!

Warm Regards,

SARAH WEINER HR GENERALIST – BENEFITS, COMPENSATION, & PAYROLL ASPEN HEIGHTS PARTNERS 1301 S. Capital of TX Hwy, Suite B201 Austin, TX 78746 Direct 512.910.3266 Confidential HR Fax 512-879-1179

ahpliving.com

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Your Retirement.

Get there one step at a time.

Aspen Heights 401(K) Plan

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Plan for what’s ahead Knowing your goals for retirement—and what it will take to reach them— is key to creating a strategy that works for you.

Learn how the plan helps you save and stay on track to reach your goals.

Choose how you want to get there Understanding investments puts you on the right path to choosing options that best meet your goals and preferences. Get the basics to boost your knowledge and make smart investing decisions.

Start moving in the right direction Your plan makes it easy for you to start saving for your future financial security. Take the first step and enroll today.

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Take the first step.

Enroll Today.

The retirement years hold many possibilities. Do you have plans for this next phase in your life?

Many of us do. Whether you see yourself working less, starting a new career, enjoying hobbies or traveling, chances are you’ll need to plan ahead and save.

Ready to enroll in the plan?

Go to page 8 to find out how to get started saving now.

The future offers the potential for a longer life and the need for more income in retirement. You may need 70%-90% of your current annual income to replace your salary and live comfortably once you stop working or change your lifestyle in retirement. We all want the financial security to afford to spend retirement as we choose. And while Social Security may help, it probably won’t be enough. It’s up to you to make up the difference—and your plan can help.

Aspen Heights 401(K) Plan can help you reach your future financial goals, and it’s easy to get started. The sooner you enroll, the sooner you can take advantage of these benefits: ●

Employer contributions

●

Tax-advantaged saving through pre-tax contributions and the Roth 401(k) option

●

Convenient, automatic payroll deductions

●

A broad range of investment options

●

Plan features that simplify planning

●

An account you can take with you

This guide contains all the information you need to get started on your path to future financial security. Take a few moments to decide how much to save, how to choose investments for your needs and goals, and open your retirement account today.

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Plan for what’s ahead.

Whatever you decide is ahead in retirement, you’ll want to be able to afford to live comfortably. The plan is a convenient way to get you started.

YOUR CONTRIBUTIONS How much you save will have a big impact on how much money you will have when you retire. You can contribute from 1% to 90% of your pre-tax salary to the plan each year. Your plan also allows you to contribute on an aftertax basis through Roth 401(k) contributions.

AN AUTOMATED WAY TO SAVE MORE Save Smart® is a plan feature that can help you save more for your future. It automatically increases your pretax plan contributions by 1, 2, or 3% annually on the date you choose—such as the month you expect to receive a raise. You can elect this feature on your plan website.

The IRS limit on your total annual contributions is $18,000 (2017). Those age fifty or over can save an additional $6,000 with catch-up contributions (2017).

Find out how to maximize your contributions to take full advantage of the employer match and tax savings your plan offers.

YOUR EMPLOYER HELPS When you participate in the plan, your employer will match 50% up to the first 6% of your eligible compensation. You decide how to invest this contribution.

See your Plan Information for details.

Starting earlier

Starting earlier can pay off Start now Saveimportant for 10 years to save enough It’s $400,138 for your future, and it’s also Wait 10 years Save for 30 years important to understand the concept of $298,072 compounded returns. The chart shows $226,072 how$376,138 starting earlier puts compounding to work for you over time. $24,000

$72,000

Earnings

Contributions

Start now* Contribute Start now for 10 years Save for 10 years $400,138

allows the account to grow an additional 10 years!

Wait 10 years** Contribute for Wait 10 years 30 years Save for 30 years $298,072

$376,138

$226,072

$24,000

$72,000

Earnings

Contributions

Save $200 a month

2

This hypothetical illustration assumes pre-tax contributions made at the beginning of each month and an annual effective rate of return of 8% and reinvestment of earnings. * Start now assumes the contributions are invested for 40 years; ** Wait 10 years assumes contributions are invested for 30 years. Results are for illustrative purposes only and are not meant to represent the past or future performance of any specific investment vehicle.

Investment return and principal value will fluctuate and, when redeemed, the investment may be worth more or less than its original cost. Taxes are due upon withdrawal. Withdrawals taken prior to age 59½ may be subject to a 10% tax penalty.

ADP makes no recommendation regarding the appropriateness of any amount you may consider contributing to your employer’s plan.

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REDUCE YOUR INCOME TAXES TODAY

BY SAVING PRE-TAX There are benefits to saving in the plan pre-tax.

Saving pre-tax lowers your current taxable income.

It allows you to pay less in taxes now and take more income home. You can see the advantage of pre-tax saving in the chart: it costs less to contribute when you save pre-tax so you may be able to afford to save more than you think.

Pre-Tax Saving It costs less than you think to save for your retirement.

Annual Salary: $30,000

Tax Bracket: 15%

Pre-tax Contribution Rate

2%

4%

6%

Weekly Plan Contribution

$11.54

$23.08

$34.62

Weekly Tax Savings

$1.73

$3.46

$5.19

Weekly Out-of-Pocket Amount

$9.81

$19.62

$29.43

amount contributed in the plan.

Annual Contribution

$600

$1200

$1800

Account Balance After 30 Years

$75,015

$150,030

$225,044

» The out-of-pocket amount is less than the You are not required to pay taxes on your savings and earnings until you make withdrawals. In retirement, you may be in a lower tax bracket because you are working part-time or not at all, so deferring taxes can be a benefit. It may also help your account compound faster by putting more money to work for you now with the money you may have paid in taxes.

CONSIDER THE ROTH 401(K) OPTION Your plan offers another tax-advantaged savings option: a Roth 401(k). With Roth, your contributions are taxed now—instead of when you retire. Your contributions and earnings grow tax-free, which means you pay no taxes when you make a withdrawal if certain conditions are met. A Roth 401(k) may be right for you if: • •

Your federal income tax rate will be higher when you retire You expect to invest for many years and reach a higher tax bracket when you retire

» »

This chart is for illustrative purposes only. This example assumes contributions made at the beginning of the month and an 8% annual effective rate of return compounded monthly. Results are not meant to represent past or future performance of any specific investment vehicle. Investment return and principal value will fluctuate and when redeemed, the investment may be worth more or less than its original cost. Taxes are due upon withdrawal. Withdrawals taken prior to age 59 1/2 may be subject to a 10% tax penalty. ADP makes no recommendation regarding the appropriateness of any amount you may consider contributing to your employer’s plan.

You Decide: Roth or Traditional 401(k)

Traditional 401(k)

Roth 401(k)

Employee Contributions

Before-tax dollars

After-tax dollars

Account Growth (earnings)

Tax-deferred until distribution

Tax-free at distribution (if distribution is qualified)

Federal Tax

Reduces current taxable income by contribution amount

Contribution is taxable in current year

Taxes paid at withdrawal

No taxes due on qualified withdrawals*

Available at age 59½

Tax-free, provided you had the account at least five years and you are: - at least 59½, or are - disabled or deceased

You can also use the Roth 401(k) calculator on the plan web site to help you decide.

Distributions

ADP makes no recommendation regarding the appropriateness of Roth versus non-Roth elective deferrals.

*Tax law requirements must be met.

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Choose how you want to get there.

INVESTMENT OPTIONS You control how your savings are invested. You have a variety of investment options in your plan to help you create the asset allocation that is right for your needs and goals. See the Performance Summary for a complete fund listing.

Asset Allocation When you make your own asset allocation decision, it’s important to spread your savings among different investments, which can help smooth the ups and downs of market cycles and reduce portfolio risk.

Your account allocation is one of the most important decisions you can make in your retirement planning and can have a big impact on your investment results. To help you think about your asset allocation, the Investor Profiler on page 5 can get you started.

In deciding how to allocate the investment of your account balance, keep in mind that some of the plan’s investment options, known as “target date funds,” contain an asset allocation strategy within the investment option itself. The target date of a target date mutual fund is the approximate date when an investor plans to begin withdrawing their money from the fund. The funds automatically change their underlying asset allocation gradually over time, becoming more conservative as the target date approaches. Choosing one of these investment options could simplify your asset allocation approach.*

NEED MORE INFORMATION? Visit www.mykplan.com to access calculators, tools and information to help with your planning.

Concepts every investor should understand: •• Put time on your side. Starting earlier can increase your chances of affording a comfortable retirement.

It will give your account more time to benefit from compounding. With more time, you can consider investing more aggressively, which may provide greater growth potential.

•• Understand risk. All investments carry some risk.

Market risk, the change in value of your investment in response to stock market conditions, is usually the risk people think of. However, inflation risk, the risk your money will not maintain its purchasing power over time, is equally important. In general, the more risk an investment carries, the greater the potential for a higher return. Those with less risk offer lower potential return.

•• Diversify. A diversified allocation can help manage risk.

Spreading your money across different asset classes can help smooth out stock market fluctuations and reduce overall risk.

•• Think long term. Consider creating a diversified investment mix taking into account your age, years to retirement and risk tolerance, and sticking to it. You’ll want to review your strategy as life changes occur or you near retirement.

•• Invest regularly. Making regular automatic contributions, like you do in the plan, is an easy way to invest. Each contribution buys shares in your investment funds—some at lower prices and some at higher prices. Over time, this process may lower the average purchase price of your investments.

* The underlying mutual funds in the portfolios of asset allocation funds are subject to stock market risk and invest in individual bonds whose yields and market values fluctuate, so that your investment may be worth more or less than its original cost. The target date of a target date mutual fund is the approximate date when an investor plans to begin withdrawing their money from the fund. The principal value of a target date fund is not guaranteed at any time, including at the target date. Keep in mind that a target date mutual fund is comprised of a mix of underlying investment options in various asset classes. Therefore, if you decide to invest in other funds in addition to a target date mutual fund, you may overweight your account in a particular asset class.

Diversification and dollar cost averaging do not guarantee a profit or protect against a loss in a declining market. There is no guarantee that your balance will increase over time.

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Personal Investor Profile

2. The main objective for my account is to: 

The asset allocations provided by this Personal Investor Profile are provided for educational purposes only and should not be construed as investment advice.

In applying any asset allocation model to your individual situation, you should consider your other assets, income and investments in addition to any balance you may have in a retirement plan. See your financial advisor before making any decision as to your asset allocation.









1. How would you best describe your investment experience and knowledge?





Keep pace with inflation.

(2 points)



$5,000 (5%) (0 points)



$10,000 (10%) (1 points)

Keep pace with the stock market.

(4 points)



$15,000 (15%) (2 points)



$20,000 (20%) (3 points)



I would not move my money at all.

(4 points)

3. If my account lost 30% of its value over a short period of time, I would be:

Answer the following questions with the corresponding point value to determine your investor profile score.



Avoid losses.

(0 points)



I am very experienced and knowledgeable about investments.

(4 points)

Extremely uncomfortable – I cannot accept large short-term losses. (0 points) Slightly uncomfortable – I may be ok with a short-term loss as long as I have time to regain those losses.

(2 points) Comfortable – Because I have time to regain those losses. (4 points)

4. I am willing to accept a greater risk of losing money in my account for the potential of higher long-term returns:

I have some experience and knowledge about investments.

(2 points)



I have very little or no investment experience and knowledge.

(0 points)

5. My account has $100,000 in it.

I would move my money to a lower risk investment if it lost _______ in one year. (Fill in the blank.)





Strongly Agree (4 points) Agree (3 points) Neutral (2 points)





Disagree (1 points) Strongly Disagree (0 points)

6. When attempting to achieve my investment goals: 

I do not want my account to lose any value, even if it will take longer to achieve my investment goals.

(0 points)



I will accept small fluctuations in my account’s value. (1 points)



I will accept moderate fluctuations in my account’s value. (2 points)



I will accept large fluctuations in my account’s value. (3 points)



I will accept extreme fluctuations in my account’s value. (4 points)

Total the points for your score.

Your Score

Find your total score in the chart below, along with your retirement timeline, to see what type of investment profile may be best for you.

This chart should only serve as a guide to help you determine your own investing comfort zone.

Years To My Retirement My Investor Score 0-2 points

3-8 points

9-16 points

17-21 points

22-24 points

0-3 years

Conservative

Conservative

Conservative

Conservative

Conservative

3-5 years

Conservative

Moderate Conservative

Moderate Conservative

Moderate Conservative

Moderate Conservative

5-7 years

Conservative

Moderate Conservative

Moderate

Moderate

Moderate

7-12 years

Conservative

Moderate Conservative

Moderate

Moderate Aggressive

Moderate Aggressive

12+ years

Conservative

Moderate Conservative

Moderate

Moderate Aggressive

Aggressive

The results of this quiz are intended to help you identify what type of investor you may be. This quiz is not intended to recommend a particular asset allocation or to provide individual advice.

5 ASPEN 2018 BENEFITS :: 80

Profiles Conservative Profile This profile may be right for you if you want to avoid a potential loss of account value, or if you are nearing retirement.

You should be willing to go without the potential for higher long-term returns in exchange for a more stable and predictable return.

Moderate Conservative Profile This profile may be right for you if your primary goal is to avoid short-term losses. However, you also want higher long-term returns to offset the effects of inflation. Your account will likely have relative stability, but in order to keep up with inflation, some fluctuations in your account value should be expected.

Moderate Profile This profile may be right for you if you are interested in balancing your level of risk and return. You want to have returns

Moderate Aggressive Profile This profile may be right for you if you have more time until retirement and can tolerate higher-than-average fluctuations in your account value. This type of allocation provides the potential for higher-than-average returns over the long term.

You should be willing to accept short-term losses and less stable returns.

Aggressive Profile This profile may be right for you if you are willing and able to stay the course through short-term gains and losses because you want the potential for higher returns over the long term. You should have a long time until retirement and a high tolerance for risk. You should be willing to accept frequent short-term losses and extreme fluctuations in account value.

Investor Profiles Match your investor profile to one of the sample asset allocation models.* Conservative

Moderate Conservative

Moderate

Moderate Aggressive

Aggressive

20% Equity

40% Equity

60% Equity

75% Equity

90% Equity

65% Fixed Income

50% Fixed Income

35% Fixed Income

25% Fixed Income

10% Fixed Income

15% Cash or Cash Equivalents

10% Cash or Cash Equivalents

5%

0%

0%

LOW

Cash or Cash Equivalents

RISK/REWARD POTENTIAL

Cash or Cash Equivalents

Cash or Cash Equivalents

HIGH

* These risk-based asset allocation models were created using the following three asset classes: Domestic Equity; Intermediate-Term Domestic Bond; and Cash Equivalent.

This Personal Investor Profile was created by and is the property of the Mesirow Financial Investment Strategies Group, a division of Mesirow Financial Investment Management, Inc. (MFIM), an SEC registered investment advisor. ADP, LLC and its affiliates (ADP) are not affiliates of MFIM, nor do they provide investment, financial, legal or tax advice to participants. The information provided herein is for informational purposes only and is not intended to be, nor should it be construed as, individualized advice or a recommendation to purchase or sell any particular investment option. In applying any asset allocation model to your individual situation, you should consider your other assets, income and investments in addition to any balance you may have in a retirement plan. In making this interactive material available, ADP makes no recommendation regarding the appropriateness of any asset allocation. Copyright Š 2017 ADP, LLC. All rights reserved. The Mesirow Financial name is a registered service mark of Mesirow Financial Holdings, Inc. Š 2017, Mesirow Financial Holdings, Inc. All rights reserved.

6 99-4603-0317

ASPEN 2018 BENEFITS :: 81

Notes ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 7 ASPEN 2018 BENEFITS :: 82

Start moving in the right direction.

ENROLL TODAY Here’s what you need to do to open your retirement account: ●

To help you reach your retirement goals, a voluntary elective contribution of 2% will be deducted pre-tax from your pay and deposited in your retirement account in the plan default fund for you. If you decide now is not the right time to start saving for your future, you can decline enrollment through the website or Voice-Response System. You can always change your mind and enroll later. See your welcome letter for more information, including important dates.

●

While establishing your account, you can also review account features that may be helpful with planning like Save Smart® and automatic Account Rebalancing. You can get information and elect them on www.mykplan.com.

Once you establish a retirement account, you can track your progress using the account resources available to help you.

If you would like to make different elections, you can review the information in this guide and either complete any necessary forms or follow the instructions to open your retirement account. ●

Review the information in this guide and either complete any necessary forms or follow the instructions to open your retirement account.

●

Designate an account beneficiary. Submit your completed form to your employer or complete this step online.

●

Determine your contribution level to the plan and whether you want to contribute at least enough to receive the maximum matching contribution under the plan (if your employer makes a matching contribution).

NAMING A BENEFICIARY FOR YOUR ACCOUNT IS IMPORTANT. In the event of your death, your account will be passed to the person(s) you name.

If you are single, or married and want to name your spouse as your sole primary beneficiary, you can designate your beneficiary online. If you are married and want to designate someone other than your spouse, you must print the form available online and follow the instructions to complete it.

Be sure to complete this important step in your retirement planning.

8

ASPEN 2018 BENEFITS :: 83

ENROLLMENT INSTRUCTIONS (Do Not Send to ADP) Follow these simple steps to enroll in your company retirement plan.

I

DECIDE HOW MUCH TO SAVE

Deductions are subject to maximum deferral and contributions limits. Refer to your Summary Plan Description (SPD) or consult your Plan Administrator to review plan limits. Through your plan, you can make: l Before-tax contributions l Roth 401(k) contributions Your plan is an automatic enrollment plan. To help you save for your retirement, a portion of your pay will automatically be deducted and deposited into your retirement savings plan account for you, unless you actively enroll or decline enrollment.

Refer to your welcome letter for information about important dates when you need to take action.

II CHOOSE YOUR INVESTMENTS

The list of your plan’s investments is on the following page(s).

III ENROLL l l

Enrolling with no prior account balance: Please use the password you received in the mail to enroll.

Enrolling with an existing account balance: Use your current password to enroll if you have an account balance in your Plan due to a rollover/employer non-elective contribution.

Log on: www.mykplan.com (if available)

OR

Call: 1-800-mykplan(1-800-695-7526)

Once you have accessed your account, follow the steps to choose your contribution amount and investments. You will receive confirmation of your enrollment.

! OTHER IMPORTA T NT CONSIDERAT A IONS Designate your beneficiary(ies): It’s an important step in managing your account because it provides a way for you to pass ownership of your account assets on to your beneficiary(ies) after your death. Either submit a completed Beneficiary Designation Form or designate your beneficiary online.

The Save Smart feature lets you increase your pre-tax contributions by 1, 2, or 3% annually on the date you choose.

It can help you meet your retirement savings goals by saving automatically over time.

You may elect Account Rebalancing to keep your asset allocation balanced. Once you’ve created your diversified allocation, this feature can keep it balanced for you.

EN_WKST 106 01-SHELL

9 ASPEN 2018 BENEFITS :: 84

227842_REENROLLWKSHTSM_11/01/17

ENROLLMENT INSTRUCTIONS II PLAN INVESTMENTS

Remember to review the fund prospectuses, which provide complete information about the funds, including fees and expenses, before choosing your investments. See the Web site or your Plan Administrator to obtain fund prospectuses.

When you create your asset allocation, your investment election must total 100%.

7J

BJ DFA Inflation Protected Securities Portfolio - Institutional Class C0 American Beacon Bridgeway Large Cap Value Fund Institutional Shares JS DFA US Core Equity 1 Portfolio - Institutional Class

2I

Vanguard Target Retirement Income Fund - Investor Class* Vanguard Target Retirement 2015 Fund - Investor Class* Vanguard Target Retirement 2020 Fund - Investor Class* Vanguard Target Retirement 2025 Fund - Investor Class* Vanguard Target Retirement 2030 Fund - Investor Class* Vanguard Target Retirement 2035 Fund - Investor Class* Vanguard Target Retirement 2040 Fund - Investor Class* Vanguard Target Retirement 2045 Fund - Investor Class* Vanguard Target Retirement 2050 Fund - Investor Class* Vanguard Target Retirement 2055 Fund - Investor Class* Vanguard Target Retirement 2060 Fund - Investor Class* Columbia Balanced Fund - Class Y*

73

Vanguard Wellesley Income Fund - Admiral Class*

MA Invesco Stable Asset Fund - ADPZ Class

8X American Beacon International Equity Fund - Institutional Class Shares AR DFA Large Cap International Portfolio - Institutional Class

RV

JPMorgan Core Plus Bond Fund - Class R6

PQ Oppenheimer International Growth Fund - Class I

0Q

Vanguard Intermediate Term Bond Index Fund Admiral Class BlackRock High Yield Bond Portfolio - Class K

PD Columbia Emerging Markets Fund - Class Y

IF SG M8 C7 RF TE YO S0 YX NN

PO

KE Vanguard Dividend Growth Fund - Investor Class D2 Alger Spectra Fund - Class Z XF American Beacon Mid Cap Value Fund - Institutional Class Shares 5W Vanguard Extended Market Index Fund - Admiral Class AI Dreyfus/The Boston Company Small/Mid Cap Growth Fund - Class Y 97 Victory Integrity Small-Cap Value Fund - Class R6 1C DFA US Small Cap Portfolio - Institutional Class NV JPMorgan US Small Company Fund - Class R6 MC Janus Henderson Venture Fund - Class N

8R Vanguard REIT Index Fund - Admiral Class

Investment options with an asterisk are Target Date Funds, whose underlying mutual funds are subject to stock market risk and that invest in individual bonds whose yields and market values fluctuate, so that your investment may be worth more or less than its original cost. The target date of a target date mutual fund is the approximate date when an investor plans to begin withdrawing their money from the fund. The principal value of a target date fund is not guaranteed at any time, including at the target date.

10

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ASPEN 2018 BENEFITS :: 85

227842_REENROLLWKSHTSM_11/01/17

Aspen Heights 401(K) Plan

ROLLOVER FORM – 280

-

Social Security #:

-

-

Phone #:

-

Employee Name: Last, First, Middle

Address: Street

Apt. # / PO Box #

City

Birth Date: Month

-

Day

-

State

Hire Date: Year

Month

-

-

Zip Code

Day

-

Year

I ROLLOVER INSTRUCTIONS The Rollover Form is used to invest prior plan money in your Plan account. The rollover must be completed within 60 days of receipt of the distribution, come from another employer’s plan or an IRA and represent all or a portion of a lump sum distribution, or an installment distribution of less than ten years. In the context of a direct rollover, in which the funds are never actually made payable to you, the 60-day period for completing a rollover is inapplicable.

Section II.A. Check (ü) the appropriate box to identify the source of this Rollover.

Section II.B. Identify the total amount of the rollover. A certified or bank check must accompany this form for the stated dollar amount. Pre-printed checks are required. Handwritten checks will be returned to the Plan Administrator. Please include the last four digits of your Social Security Number and Plan Number on the check made payable to Reliance Trust Company.

Section III. Read the acknowledgment, and then sign and date the form.

Note: If you have not previously enrolled in the Plan, you must complete a Beneficiary Form and give it to your Plan Administrator. Do not send to ADP.

II ROLLOVER AMOUNT/SOURCE A. This rollover is a distribution from: o Individual Retirement Account o SIMPLE IRA (IRA must be in existence for at least 2 years) o §457 Plan o §403(b) Tax Sheltered Annuity o Qualified Plan of (check one): o an Unrelated Employer o a Related Employer Note: If you do not check a box, we will understand you have certified that the rollover is from an unrelated employer.

B. Select rollover type: . o Before-Tax 401(k) $

TOTAL ROLLOVER AMOUNT o Roth 401(k)

$

.

TOTAL ROLLOVER AMOUNT

=$

.

+$

Contributions

.

Earnings

NOTE: Rollovers of Roth 401(k) monies may only be made via direct rollover and may not be rolled over from an IRA.

III ACKNOWLEDGMENT, ROLLOVER INVESTMENT DIRECTION AND SIGNATURE I have read and understand the Summary Plan Description and Participant Fee Disclosure Statement, have completed the Beneficiary Form if I have not previously enrolled in the plan, and agree to be bound by the provisions of the Plan. I have also reviewed a description of each of the funds, and understand the objectives, risks, expenses and charges associated with each. I certify that: l I received the distribution from the source indicated above within the last 60 days (60-day requirement not applicable in the case of a direct rollover). l The rollover is from the rollover source indicated above and has not been combined with any money that would disqualify the rollover. l No portion of this rollover contribution represents amounts received as a hardship distribution from an employer plan.

I understand that if I do not have a plan account one will be established for my rollover contribution and invested in the plan default fund. Once my account has been established, I will be mailed my account access information and can make investment allocation changes through the plan website or Voice Response System. If I already have a plan account established, I direct that my rollover contribution be invested in accordance with my investment election on file.

In an effort to prevent short-term trading and market timing, many investment companies have established excessive trading and/or redemption fee policies for certain investments. ADP Retirement Services, whenever possible, implements the investment company’s market timing policy (please review the fund’s prospectus for information on a specific fund company’s policies). However, there are instances when ADP Retirement Services may need to implement its own market timing policy, which could differ from the investment company’s policy, in order to ensure compliance with the fund’s prospectus. Because investment options in your retirement savings plan may be subject to these policies, please refer to your Plan Participant Web site (or, if the Web site is not available to you, call a Client Services Representative) for additional information.

Signature of Employee/Participant

Date

FOR PLAN ADMINISTRATOR USE ONLY (MUST BE COMPLETED)

Company Code:

Date Received: __________________________

Plan Administrator Approval: _________________________________

Date Roth 401(k) contributions began: (If not provided, ADP will use date contribution is received)

_______ / _______ / 20_______

Recordkeeping Plan #:

280-126

2 2 7 8 4 2 !!!!!!

227842_ENROLLFORMSM_11/01/17

11 ASPEN 2018 BENEFITS :: 86

12

ASPEN 2018 BENEFITS :: 87

Performance Summary

For the month ending September 30, 2017

Current performance may be lower or higher than the performance data quoted. For most recent performance, go to www.mykplan.com.

1

Fund Name/Inception

Morningstar Category

2

Ticker

Month

Average Annual Total Returns (NAV) QTR3 1 Yr 3 Yr 5 Yrs 10 Yrs4

Expense Ratio Net Gross

1.58%(I) 5.35% 5.35% 7.65% 4.12%

0.45% 0.40% 0.07% 0.53% 0.12%

0.45% 0.43% 0.07% 0.54% 0.12%

4.68% 4.87% 6.91% 4.87% 8.07% 5.14% 8.85% 5.21% 9.58% 5.26% 10.29% 5.46% 10.79% 5.73% 10.90% 5.77% 10.91% 5.77% 10.88% 11.26%(I) 10.87% 11.09%(I) N/A 10.91%(I) 6.88% 6.89%

0.13% 0.14% 0.14% 0.14% 0.15% 0.15% 0.16% 0.16% 0.16% 0.16% 0.16% 0.66% 0.15%

0.13% 0.14% 0.14% 0.14% 0.15% 0.15% 0.16% 0.16% 0.16% 0.16% 0.16% 0.66% 0.15%

7.53%

0.73%

0.73%

14.39% 7.84% 12.80% 8.20% 15.02% 13.80%(I) 14.48% 8.54%

0.19% 0.30% 0.89% 0.90%

0.19% 0.30% 0.99% 0.90%

Income Invesco Stable Asset Fund - ADPZ Class (07/2014) JPMorgan Core Plus Bond Fund - Class R6 (02/2005) Vanguard Intermediate Term Bond Index Fund - Admiral Class (11/2001) BlackRock High Yield Bond Portfolio - Class K (11/1998) DFA Inflation Protected Securities Portfolio - Institutional Class (09/2006)

N/A Intermediate-Term Bond Intermediate-Term Bond High Yield Bond Inflation-Protected Bond

N/A JCPUX VBILX BRHYX DIPSX

0.16% -0.36% -0.82% 0.96% -1.00%

0.49% 1.09% 0.83% 2.32% 0.86%

1.76% 1.31% -0.51% 9.73% -1.00%

1.61% N/A 3.30% 3.23% 3.25% 2.31% 5.25% 6.66% 1.72% -0.09%

Growth & Income Vanguard Target Retirement Income Fund - Investor Class (10/2003) Vanguard Target Retirement 2015 Fund - Investor Class (10/2003) Vanguard Target Retirement 2020 Fund - Investor Class (06/2006) Vanguard Target Retirement 2025 Fund - Investor Class (10/2003) Vanguard Target Retirement 2030 Fund - Investor Class (06/2006) Vanguard Target Retirement 2035 Fund - Investor Class (10/2003) Vanguard Target Retirement 2040 Fund - Investor Class (06/2006) Vanguard Target Retirement 2045 Fund - Investor Class (10/2003) Vanguard Target Retirement 2050 Fund - Investor Class (06/2006) Vanguard Target Retirement 2055 Fund - Investor Class (08/2010) Vanguard Target Retirement 2060 Fund - Investor Class (01/2012) Columbia Balanced Fund - Class Y (11/2012) Vanguard Wellesley Income Fund - Admiral Class (05/2001)

Target-Date Retirement VTINX Target-Date 2015 VTXVX Target-Date 2020 VTWNX Target-Date 2025 VTTVX Target-Date 2030 VTHRX Target-Date 2035 VTTHX Target-Date 2040 VFORX Target-Date 2045 VTIVX Target-Date 2050 VFIFX Target-Date 2055 VFFVX Target-Date 2060+ VTTSX Allocation--50% to 70% EquityCBDYX Allocation--30% to 50% EquityVWIAX

0.37% 0.70% 1.03% 1.22% 1.44% 1.66% 1.81% 1.91% 1.91% 1.93% 1.91% 0.77% 0.83%

1.96% 2.60% 3.14% 3.51% 3.88% 4.17% 4.51% 4.65% 4.65% 4.68% 4.65% 2.86% 2.27%

5.26% 7.94% 10.16% 11.74% 13.25% 14.75% 16.25% 16.83% 16.83% 16.85% 16.83% 10.85% 6.26%

4.28% 5.34% 6.22% 6.76% 7.19% 7.60% 7.96% 8.14% 8.14% 8.10% 8.08% 7.51% 6.25%

Large Value

BRLVX

2.97%

3.69% 14.83%

Large Blend Large Blend Large Growth Mid-Cap Value

DFEOX VDIGX ASPZX AACIX

3.27% 1.79% -0.19% 4.41%

4.82% 2.75% 5.60% 3.96%

Mid-Cap Blend Mid-Cap Growth

VEXAX DBMYX

4.23% 3.26%

4.95% 18.99% 6.03% 22.43%

10.44% 14.21% 8.31% 11.25% N/A 11.95%(I)

0.08% 0.68%

0.08% 0.68%

Small Value Small Blend Small Blend Small Growth

MVSSX DFSTX JUSMX JVTNX

6.38% 7.07% 5.06% 3.99%

5.94% 5.42% 4.43% 5.45%

10.49% 11.76% 11.24% 12.80%

1.00% 0.37% 0.74% 0.68%

1.00% 0.37% 0.75% 0.68%

Growth American Beacon Bridgeway Large Cap Value Fund - Institutional Shares (10/2003) DFA US Core Equity 1 Portfolio - Institutional Class (09/2005) Vanguard Dividend Growth Fund - Investor Class (05/1992) Alger Spectra Fund - Class Z (12/2010) American Beacon Mid Cap Value Fund - Institutional Class Shares (11/2005) Vanguard Extended Market Index Fund - Admiral Class (11/2000) Dreyfus/The Boston Company Small/Mid Cap Growth Fund - Class Y (07/2013) Aggressive Growth Victory Integrity Small-Cap Value Fund - Class R6 (06/2012) DFA US Small Cap Portfolio - Institutional Class (03/1992) JPMorgan US Small Company Fund - Class R6 (11/2011) Janus Henderson Venture Fund - Class N (05/2012)

1

The 7-day yield more closely reflects the current earnings of the money market fund than the total return quotation.

2 Commingled Funds are not publicly traded mutual funds and are not listed in public stock market listings such as the Wall Street Journal.

3 Quarter-end returns are for the most recent quarter-end performance. (Quarter-end periods are 3/31, 6/30, 9/30 and 12/31.)

4 10 year or since inception of the fund.

19.53% 14.11% 20.64% 20.91%

21.68% 19.76% 15.08% 18.35%

8.91% 14.75% 10.28% 9.56% 11.19% 9.80%

14.52% 16.13%(I) 14.47% 8.90% 14.29% 15.96%(I) 15.15% 15.65%(I)

Investment Returns and principal value of an investment will fluctuate so that when an investor's shares are redeemed, they may be worth more or less than the original cost. The returns represent past performance. Past performance is no guarantee of future results.

An expense ratio is a fund's annual operating expenses expressed as a percentage of average net assets and includes management fees, administrative fees, and any marketing and distribution fees. Expense ratios directly reduce returns to investors.

The expense ratio typically includes the following types of fees: accounting, administrator, advisor, auditor, board of directors, custodial, distribution (12b-1), legal, organizational, professional, registration, shareholder reporting, sub-advisor, and transfer agency. The expense ratio does not reflect the fundâ&#x20AC;&#x2122;s brokerage costs or any investor sales charges. For publicly traded mutual funds, the net prospectus expense ratio is collected from the fund's most recent prospectus and provided by Morningstar. This is the percentage of fund assets paid for operating expenses and management fees. In contrast to the net expense ratio, the gross expense ratio does not reflect any fee waivers in effect during the time period. Morningstar pulls the prospectus gross expense ratio from the fundâ&#x20AC;&#x2122;s most recent prospectus.

Commingled Fund expense ratios are provided by the investment managers.

For complete information on the funds, please see the prospectus and consider the investment objective, risks, charges and expenses before investing. The prospectus contains this and other important information related to the funds and the investment company. Please read it carefully before investing. To obtain a prospectus, please see your plan sponsor or your plan administrator or go to www.mykplan.com.

Investment options are available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Blvd, Roseland, NJ. Member FINRA. ASPEN 2018 BENEFITS :: 88

Performance Summary

For the month ending September 30, 2017

Current performance may be lower or higher than the performance data quoted. For most recent performance, go to www.mykplan.com.

1

Fund Name/Inception Aggressive Growth (continued) American Beacon International Equity Fund - Institutional Class Shares (08/1991) DFA Large Cap International Portfolio - Institutional Class (07/1991) Oppenheimer International Growth Fund - Class I (03/2012) Columbia Emerging Markets Fund - Class Y (11/2012) Vanguard REIT Index Fund - Admiral Class (11/2001)

1

Morningstar Category

Ticker

Foreign Large Value Foreign Large Blend Foreign Large Growth Diversified Emerging Mkts Real Estate

The 7-day yield more closely reflects the current earnings of the money market fund than the total return quotation.

2 Commingled Funds are not publicly traded mutual funds and are not listed in public stock market listings such as the Wall Street Journal.

3 Quarter-end returns are for the most recent quarter-end performance. (Quarter-end periods are 3/31, 6/30, 9/30 and 12/31.)

4 10 year or since inception of the fund.

Month

Average Annual Total Returns (NAV) QTR3 1 Yr 3 Yr 5 Yrs 10 Yrs4

Expense Ratio Net Gross

AAIEX

3.10%

5.47% 18.72%

3.74%

7.80%

1.84%

0.70%

0.70%

DFALX OIGIX CEKYX VGSLX

2.44% 5.65% 19.45% 2.40% 5.79% 16.04% 1.39% 11.50% 26.13% -0.12% 0.89% 0.42%

4.92% 7.26% 8.12% 9.53%

8.07% 9.25% N/A 9.48%

1.60% 8.74%(I) 6.56%(I) 6.02%

0.23% 0.70% 1.19% 0.12%

0.23% 0.70% 1.22% 0.12%

2

Investment Returns and principal value of an investment will fluctuate so that when an investor's shares are redeemed, they may be worth more or less than the original cost. The returns represent past performance. Past performance is no guarantee of future results.

An expense ratio is a fund's annual operating expenses expressed as a percentage of average net assets and includes management fees, administrative fees, and any marketing and distribution fees. Expense ratios directly reduce returns to investors.

The expense ratio typically includes the following types of fees: accounting, administrator, advisor, auditor, board of directors, custodial, distribution (12b-1), legal, organizational, professional, registration, shareholder reporting, sub-advisor, and transfer agency. The expense ratio does not reflect the fundâ&#x20AC;&#x2122;s brokerage costs or any investor sales charges. For publicly traded mutual funds, the net prospectus expense ratio is collected from the fund's most recent prospectus and provided by Morningstar. This is the percentage of fund assets paid for operating expenses and management fees. In contrast to the net expense ratio, the gross expense ratio does not reflect any fee waivers in effect during the time period. Morningstar pulls the prospectus gross expense ratio from the fundâ&#x20AC;&#x2122;s most recent prospectus.

Commingled Fund expense ratios are provided by the investment managers.

For complete information on the funds, please see the prospectus and consider the investment objective, risks, charges and expenses before investing. The prospectus contains this and other important information related to the funds and the investment company. Please read it carefully before investing. To obtain a prospectus, please see your plan sponsor or your plan administrator or go to www.mykplan.com.

Investment options are available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Blvd, Roseland, NJ. Member FINRA. ASPEN 2018 BENEFITS :: 89

Invesco Stable Asset Fund - ADPZ Class STRATEGY: The primary investment objective of the Fund will be to seek the preservation of principal and to provide interest income reasonably obtained under prevailing market conditions and rates, consistent with seeking to maintain required liquidity. The Fund’s returns are based on returns generated by an actively-managed, highly diversified portfolio of investment grade, fixed and floating rate securities. The Fund may invest in such securities directly or indirectly through commingled investment vehicles (the “building block strategy”). This building block strategy may provide greater diversification than could be achieved by investing in individual bonds. This building block strategy also may reduce the unintended impact on portfolio characteristics created by participant cash flow.

JPMorgan Core Plus Bond Fund - Class R6 STRATEGY: The investment seeks a high level of current income by investing primarily in a diversified portfolio of high-, medium- and low-grade debt securities. The fund will normally invest at least 80% of its net assets plus the amount of borrowings for investment purposes in bonds. Under normal conditions, at least 65% of the fund's total assets must be invested in securities that, at the time of purchase, are rated investment grade. It may invest up to 35% of its net assets in foreign securities, including securities denominated in foreign currencies. The fund's average weighted maturity will ordinarily range between five and twenty years.

Vanguard Intermediate Term Bond Index Fund - Admiral Class STRATEGY: The investment seeks the performance of the Bloomberg Barclays U.S. 5-10 Year Government/Credit Float Adjusted Index.

Bloomberg Barclays U.S. 5-10 Year Government/Credit Float Adjusted Index includes all medium and larger issues of U.S. government, investment-grade corporate and investment-grade international dollar-denominated bonds that have maturities between 5 and 10 years and are publicly issued. All of its investments will be selected through the sampling process, and at least 80% of its assets will be invested in bonds held in the index.

BlackRock High Yield Bond Portfolio - Class K STRATEGY: The investment seeks to maximize total return, consistent with income generation and prudent investment management. The fund invests primarily in non-investment grade bonds with maturities of ten years or less. It normally invests at least 80% of its assets in high yield bonds. The fund may invest up to 30% of its assets in non-dollar denominated bonds of issuers located outside of the United States. Its investment in non-dollar denominated bonds may be on a currency hedged or unhedged basis. The fund may also invest in convertible and preferred securities.

DFA Inflation Protected Securities Portfolio - Institutional Class STRATEGY: The investment seeks to provide inflation protection and earn current income consistent with inflation-protected securities. As a non-fundamental policy, under normal circumstances, the Portfolio will invest at least 80% of its net assets in inflation-protected securities.

Inflation-protected securities (also known as inflation-indexed securities) are securities whose principal and/or interest payments are adjusted for inflation, unlike conventional debt securities that make fixed principal and interest payments.

Vanguard Target Retirement Income Fund - Investor Class STRATEGY: The investment seeks to provide current income and some capital appreciation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors currently in retirement. Its indirect bond holdings are a diversified mix of short-, intermediate-, and long-term U.S. government, U.S. agency, and investment-grade U.S. corporate bonds; inflation-protected public obligations issued by the U.S. Treasury; mortgage-backed and asset-backed securities; and government, agency, corporate, and securitized investment-grade foreign bonds issued in currencies other than the U.S. dollar.

Vanguard Target Retirement 2015 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2015 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Vanguard Target Retirement 2020 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2020 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Vanguard Target Retirement 2025 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2025 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

For complete information on the funds, please see the prospectus and consider the investment objective, risks, charges and expenses before investing. The prospectus contains this and other important information related to the funds and the investment company. Please read it carefully before investing. To obtain a prospectus, please see your plan sponsor or your plan administrator or go to www.mykplan.com.

Investment options are available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Blvd, Roseland, NJ. Member FINRA. ASPEN 2018 BENEFITS :: 90

Vanguard Target Retirement 2030 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2030 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Vanguard Target Retirement 2055 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2055 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Vanguard Target Retirement 2035 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2035 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Vanguard Target Retirement 2060 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2060 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Vanguard Target Retirement 2040 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2040 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Columbia Balanced Fund - Class Y STRATEGY: The investment seeks high total return by investing in common stocks and debt securities. Under normal circumstances, the fund invests in a mix of equity and debt securities. Its assets are allocated among equity and debt securities (which include cash and cash equivalents) based on an assessment of the relative risks and returns of each asset class. The fund generally will invest between 35% and 65% of its net assets in each asset class, and in any event will invest at least 25% and no more than 75% of its net assets in each asset class under normal circumstances.

Vanguard Target Retirement 2045 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2045 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

Vanguard Wellesley Income Fund - Admiral Class STRATEGY: The investment seeks to provide long-term growth of income and a high and sustainable level of current income, along with moderate long-term capital appreciation. The fund invests approximately 60% to 65% of its assets in investment-grade fixed income securities, including corporate, U.S. Treasury, and government agency bonds, as well as mortgage-backed securities. The remaining 35% to 40% of fund assets are invested in common stocks of companies that have a history of above-average dividends or expectations of increasing dividends.

Vanguard Target Retirement 2050 Fund - Investor Class STRATEGY: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests in other Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within a few years of 2050 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assets allocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.

American Beacon Bridgeway Large Cap Value Fund - Institutional Shares STRATEGY: The investment seeks to provide long-term total return on capital, primarily through capital appreciation and some income. The fund invests in a diversified portfolio of stocks of large capitalization companies that are listed on the New York Stock Exchange, NYSE MKT, and NASDAQ. Under normal market conditions, at least 80% of Fund net assets (plus borrowings for investment purposes) are invested in stocks from among those in the large-cap category at the time of purchase.

For complete information on the funds, please see the prospectus and consider the investment objective, risks, charges and expenses before investing. The prospectus contains this and other important information related to the funds and the investment company. Please read it carefully before investing. To obtain a prospectus, please see your plan sponsor or your plan administrator or go to www.mykplan.com.

Investment options are available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Blvd, Roseland, NJ. Member FINRA. ASPEN 2018 BENEFITS :: 91

DFA US Core Equity 1 Portfolio - Institutional Class STRATEGY: The investment seeks to achieve long-term capital appreciation.

The fund purchases a broad and diverse group of securities of U.S. companies with a greater emphasis on small capitalization and value companies as compared to their representation in the U.S. Universe. The Advisor generally defines the U.S. Universe as a market capitalization weighted portfolio of U.S. operating companies listed on the New York Stock Exchange ("NYSE"), NYSE MKT LLC, Nasdaq Global Market, Nasdaq Capital Market, or such other securities exchanges deemed appropriate by the Advisor.

Dreyfus/The Boston Company Small/Mid Cap Growth Fund - Class Y STRATEGY: The investment seeks long-term growth of capital. To pursue its goal, the fund normally invests at least 80% of its net assets, plus any borrowings for investment purposes, in equity securities of small-cap and mid-cap U.S. companies. The adviser currently considers small-cap and mid-cap companies to be those with total market capitalizations that are equal to or less than the total market capitalization of the largest company included in the Russell 2500TM Growth Index (the index), the fund's benchmark index. The fund is non-diversified.

Vanguard Dividend Growth Fund - Investor Class STRATEGY: The investment seeks to provide, primarily, a growing stream of income over time and, secondarily, long-term capital appreciation and current income. The fund invests primarily in stocks that tend to offer current dividends. It focuses on high-quality companies that have prospects for long-term total returns as a result of their ability to grow earnings and their willingness to increase dividends over time. These stocks typically-but not always-will be large-cap, will be undervalued relative to the market, and will show potential for increasing dividends. The fund seeks to be diversified across industry sectors.

Victory Integrity Small-Cap Value Fund - Class R6 STRATEGY: The investment seeks to provide long-term capital growth. The Adviser pursues long-term capital growth in the fund by investing, under normal circumstances, at least 80% of the fund's net assets in equity securities (i.e., common stocks, preferred stocks, convertible securities and rights and warrants) of small-capitalization companies.

Small-capitalization companies mean those companies with market capitalizations within the range of companies included in the Russell 2000 Index.

Alger Spectra Fund - Class Z STRATEGY: The investment seeks long-term capital appreciation. The fund invests primarily in the equity securities of companies of any size that Fred Alger Management, Inc. believes demonstrate promising growth potential.

It can leverage, that is, borrow money to purchase additional securities.

The fund can invest in foreign securities.

American Beacon Mid Cap Value Fund - Institutional Class Shares STRATEGY: The investment seeks long-term capital appreciation and current income. Under normal circumstances, at least 80% of the fund's net assets (plus the amount of any borrowings for investment purposes) are invested in equity securities of middle market capitalization U.S. companies. These companies have market capitalizations within the market capitalization range of the companies in the Russell Midcap Index at the time of investment.

Vanguard Extended Market Index Fund - Admiral Class STRATEGY: The investment seeks to track a benchmark index that measures the investment return of small- and mid-capitalization stocks.

The fund employs an indexing investment approach designed to track the performance of S&P Completion Index, a broadly diversified index of stocks of small and mid-size U.S. companies. It invests by sampling the index, meaning that it holds a broadly diversified collection of securities that, in the aggregate, approximates the full index in terms of key characteristics. These characteristics include industry weightings and market capitalization, as well as certain financial measures, such as price/earnings ratio and dividend yield.

DFA US Small Cap Portfolio - Institutional Class STRATEGY: The investment seeks long-term capital appreciation. The fund, using a market capitalization weighted approach, purchases a broad and diverse group of readily marketable securities of U.S. small cap companies.

A company's market capitalization is the number of its shares outstanding times its price per share. In general, the higher the relative market capitalization of the U.S. small cap company, the greater its representation in the Portfolio.

JPMorgan US Small Company Fund - Class R6 STRATEGY: The investment seeks to provide high total return from a portfolio of small company stocks. Under normal circumstances, the fund invests at least 80% of its assets in equity securities of small cap U.S. companies. "Assets" means net assets, plus the amount of borrowings for investment purposes. Small cap companies are companies with market capitalizations similar to those within the universe of the Russell 2000 Index at the time of purchase.

Janus Henderson Venture Fund - Class N STRATEGY: The investment seeks capital appreciation. The fund pursues its investment objective by investing at least 50% of its equity assets in small-sized companies. It may also invest in larger companies with strong growth potential or relatively well-known and large companies with potential for capital appreciation. Small-sized companies are defined by the portfolio manager as those companies whose market capitalization falls within the range of companies in the Russell 2000 Growth Index at the time of purchase. The fund may also invest in foreign securities, which may include investments in emerging markets.

For complete information on the funds, please see the prospectus and consider the investment objective, risks, charges and expenses before investing. The prospectus contains this and other important information related to the funds and the investment company. Please read it carefully before investing. To obtain a prospectus, please see your plan sponsor or your plan administrator or go to www.mykplan.com.

Investment options are available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Blvd, Roseland, NJ. Member FINRA. ASPEN 2018 BENEFITS :: 92

American Beacon International Equity Fund - Institutional Class Shares STRATEGY: The investment seeks long-term capital appreciation. The fund normally invests at least 80% of its net assets (plus the amount of any borrowings for investment purposes) in common stocks and securities convertible into common stocks (collectively, "stocks") of issuers based in at least three different countries located outside the United States. It primarily invests in countries comprising the Morgan Stanley Capital International Europe Australasia and Far East Index ("MSCI EAFE Index").

The MSCI EAFE Index is comprised of equity securities of companies from various industrial sectors whose primary trading markets are located outside the United States.

DFA Large Cap International Portfolio - Institutional Class STRATEGY: The investment seeks long-term capital appreciation. The fund will invest at least 80% of its net assets in securities of large cap companies in the particular markets in which the Portfolio invests. The Advisor determines the minimum market capitalization of a large company with respect to each country or region in which the Portfolio invests. It also may purchase or sell futures contracts and options on futures contracts for foreign or U.S. equity securities and indices, to adjust market exposure based on actual or expected cash inflows to or outflows from the Portfolio.

Oppenheimer International Growth Fund - Class I STRATEGY: The investment seeks capital appreciation. The fund mainly invests in the common stock of growth companies that are domiciled or have their primary operations outside of the United States. It may invest 100% of its assets in securities of foreign companies. The fund may invest in emerging markets as well as in developed markets throughout the world.

It normally will invest at least 65% of its total assets in common and preferred stocks of issuers in at least three different countries outside of the United States, and emphasize investments in common stocks of issuers that the portfolio managers consider to be "growth" companies.

Columbia Emerging Markets Fund - Class Y STRATEGY: The investment seeks long-term capital appreciation. The fund invests at least 80% of its net assets (including the amount of any borrowings for investment purposes) in equity securities (including, but not limited to, common stocks, preferred stocks and securities convertible into common or preferred stocks) of companies located in emerging market countries. Emerging market countries include those countries whose economies are considered to be developing or emerging from underdevelopment. It may invest in a variety of countries, industries and sectors and does not attempt to invest a specific percentage of its assets in any given country, industry or sector.

Vanguard REIT Index Fund - Admiral Class STRATEGY: The investment seeks to provide a high level of income and moderate long-term capital appreciation by tracking the performance of a benchmark index that measures the performance of publicly traded equity REITs. The fund employs an indexing investment approach designed to track the performance of the MSCI US REIT Index. The index is composed of stocks of publicly traded equity real estate investment trusts (known as REITs). The adviser attempts to replicate the index by investing all, or substantially all, of its assets in the stocks that make up the index, holding each stock in approximately the same proportion as its weighting in the index.

ADDITIONAL DISCLOSURES Investment options are available through ADP Broker-Dealer, Inc., a subsidiary of ADP, One ADP Blvd, Roseland, NJ. Member FINRA. ADP Broker-Dealer, Inc. is not an administrator as defined in Section 3(16)A of the Employee Retirement Income Security Act of 1974 (ERISA) and in Section 414(g) of the Internal Revenue Code as amended, nor is it a "fiduciary" within the meaning of ERISA Section 3(21).

NAV (Net Asset Value) is determined by calculating the total assets, deducting total liabilities and dividing the result by the number of shares outstanding.

Performance information for all publicly traded mutual funds, excluding Money Market funds, is provided by Morningstar®. Performance information for Money Market funds and certain other types of funds is provided by the respective fund manager. © 2003 Morningstar, Inc. All Rights Reserved. The information contained herein: (1) is proprietary to Morningstar and/or its content providers; (2) may not be copied or distributed; and (3) is not warranted to be accurate, complete or timely.

Neither Morningstar, ADP, nor its content providers is responsible for any damages or losses arising from any use of this information.

Expressed in percentage terms, Morningstar's calculation of total return is determined each month by taking the change in monthly net asset value, reinvesting all income and capital-gains distributions during that month, and dividing by the starting NAV. Reinvestments are made using the actual reinvestment NAV, and daily payoffs are reinvested monthly.

The Investment Strategy is provided by Morningstar® for all publicly traded mutual funds. Investment Strategy information for Money Market funds and certain other types of funds are provided by the respective fund manager.

Investment Type Definitions: The investment types are four broad investment categories; each fund is categorized based on where the fund is listed in Morningstar, Inc.'s investment category. Income: Money Market, Stable Value, and Fixed Income investment funds. Growth and Income: Balanced and Lifestyle investment funds. Growth: Large and Mid Capitalization investment funds.

Aggressive Growth: Small Capitalization, Specialty, Foreign Stock and World Stock investment funds.

The Morningstar Category identifies funds based on their actual investment styles as measured by their underlying portfolio holdings (portfolio statistics and compositions over the past three years). If the fund is new and has no portfolio, Morningstar estimates where it will fall before assigning a more permanent category. When necessary, Morningstar may change a category assignment based on current information.

For complete information on the funds, please see the prospectus and consider the investment objective, risks, charges and expenses before investing. The prospectus contains this and other important information related to the funds and the investment company. Please read it carefully before investing. To obtain a prospectus, please see your plan sponsor or your plan administrator or go to www.mykplan.com.

Investment options are available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Blvd, Roseland, NJ. Member FINRA. ASPEN 2018 BENEFITS :: 93

The Morningstar fund summaries provided above were prepared by others for general research purposes and are made available by ADP, LLC (ADP) in a non-fiduciary capacity. ADP makes this information available solely for the purpose of providing general reference material and not as an investment recommendation or advice.

ASPEN 2018 BENEFITS :: 94

Notes ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

ASPEN 2018 BENEFITS :: 95

Plan information

ACCOUNT ACCESS You can access your account anytime.* ● www.mykplan.com ● 1-800-695-7526 You may also speak with a Service Representative Monday through Friday 8 am– 9 pm ET on days when the New York Stock Exchange is open.

PLAN ELIGIBILITY You can take advantage of this employee benefit as soon as you have met your plan’s age and service eligibility requirements: ● You must have completed 6 month(s) of service by the next plan entry date.

CONTRIBUTIONS ● Pre-tax: 1% to 90% ● Roth 401k: 1% to 90% To help you reach your retirement goals, 2% will be deducted pre-tax from your pay and invested in your plan’s default fund for you, unless you elect otherwise. Refer to your welcome letter for dates when you need to take action. ● If you’re 50 or older, you may also make a catch-up contribution in excess of Internal Revenue Code or plan limits. You may save an additional $6,000 in your plan.

EMPLOYER CONTRIBUTIONS ● Your company will match 50% of your salary deferrals up to the first 6% of your eligible compensation. ● There may be special requirements for you to receive your company contributions.

VESTING Your contributions and any amounts you rolled into the plan, adjusted for gains and losses, are always 100% yours.

Your company contribution account vests according to the following schedule: Years of service: Match % vested:

1 100%

2

3

4

5

6

7

PLAN INVESTMENTS You choose how to invest your savings. You may select from the following: ● The variety of investments listed in the Performance Summary.

LOANS Your plan allows you to borrow from your savings. (A fee may apply.) ● Number of loans outstanding at any one time: 2 ● Minimum loan amount: $500 ● Maximum repayment period: Generally, 5 years, unless for the purchase of a primary residence. ● Interest rate: Prime + 2%

*Except during scheduled maintenance.

Customer Service Representatives are employed by ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Boulevard, Roseland, NJ 07068, Member FINRA. Investment options available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Boulevard, Roseland, NJ 07068. Member FINRA. For more information on mutual funds, including fees and expenses, review the prospectus.

21 ASPEN 2018 BENEFITS :: 96

Plan information

WITHDRAWALS Types: ● Rollover ● Age 59½ ● Hardship Special rules: Special rules exist for each type of withdrawal. You may be subject to a 10% penalty in addition to federal and state taxes if you withdraw money before age 59½. See your Participant Website for more information.

DISTRIBUTIONS Vested savings may be eligible for distribution upon retirement, death, disability or termination of employment.

ROLLOVERS Rollovers are accepted into the plan, even if you have not yet met the plan’s age and service requirements. See the Rollover form for instructions if you are interested.

ACCOUNT MANAGEMENT FEATURES You may elect the following plan features online at www.mykplan.com.

Save Smart® allows you to save gradually over time, as you can afford to, to help you meet your retirement savings goals.

This feature lets you increase your pre-tax plan contribution by 1, 2, or 3% annually on the date you choose.

Automatic Account Rebalancing is a tool that can help you keep your current investment mix (balance by investment fund) consistent with your current investment strategy for new contributions. Once you have made an investment allocation election for new contributions, Automatic Account Rebalancing will rebalance your account as often as you choose: quarterly, semi-annually, or annually.

Participant investment advisory services from GuidedChoice® Your employer has chosen to make GuidedChoice® services available to plan participants. GuidedSavings® is the investment advisory service from GuidedChoice® Asset Management. You may access and use certain investment advisory components provided by GuidedChoice® without incurring any fee. If you elect to enroll in the GuidedChoice® Managed Accounts service, you will pay a yearly fee. For more information or to enroll in the service, please visit www.mykplan.com.

For information regarding eligibility, fees, investments, and risk, refer to the GuidedChoice®-ADP Disclosure Document available within the GuidedSavings® application or by contacting GuidedChoice® (800) 242-6182 or help@guidedchoice.com.

ADP provides technology services that facilitate your Plan's connectivity to GuidedChoice®. But doing so does not mean ADP recommends GuidedChoice® or GuidedSavings® services. If you have any questions about GuidedChoice® or GuidedSavings® services, please contact your employer, who has chosen to make these services available to you.

22

ASPEN 2018 BENEFITS :: 97

Notes ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 23 ASPEN 2018 BENEFITS :: 98

Notes ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 24

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ASPEN 2018 BENEFITS :: 99

Take the first step.

Enroll Today.

ACCOUNT RESOURCES Once you set up your account, it’s easy to stay connected and get information.

Online: www.mykplan.com The Participant Website provides instant access to your retirement account and the ability to make changes and perform transactions. You’ll also find tools and calculators to help with your investment planning decisions so you can make the most of your plan benefit:

If you were provided with access information at your enrollment meeting, you can enroll online now at https://www.mykplan.com/enroll You’ll need to enter the plan number and passcode you received at the enrollment meeting: Plan number: 227842

●

Research plan investments

Passcode: _______________

●

Make investment elections

This passcode expires on: _______________

●

Change your contribution amounts

●

Elect Save Smart® and automatic Account Rebalancing

●

Get prospectuses

Phone: 1-800-695-7526 The Voice Response System connects you to your plan account over the phone. Call 1-800-695-7526 to get account information and perform many of the transactions available on the Participant Website.

You can also speak to a Customer Service Representative Monday – Friday, 8am – 9pm ET.

QUARTERLY ACCOUNT STATEMENT Stay informed about your progress. Your statement has details about your account, investment performance, and account activity for the period. Available on your Participant Website.

Customer Service Representatives are employed by ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Boulevard, Roseland, NJ 07068.

Member FINRA.

AFTER YOU OPEN YOUR ACCOUNT AND YOUR PLAN IS LIVE, YOU CAN: ●

access the resources on the Participant Website and Voice-Response System

●

speak to a representative

●

review your quarterly account statements (when available)

●

access GuidedChoice® services

Use your User ID and Password to get your account information and access the site. Your Password will be mailed to you. If you lose your Password or want to change it, just call 1-800-695-7526 or go to www.mykplan.com and follow the prompts.

WANT TO LEARN MORE? Scan the code with your mobile device to enroll.

ASPEN 2018 BENEFITS :: 100

Get there one step at a time.

000001_ENG_010001

ADP: A Global Leader Founded in 1949, Automatic Data Processing, Inc. (ADP) and its companies bring more than 60 years of unrivaled industry experience. ADP is a strong, stable partner you can rely on:

• Serving more than 620,000 businesses in more than 125 countries1 • Exceptionally strong Aa1 credit rating from Moody’s and AA from Standard & Poor’s2 • Pays approximately 24 million (1 in 6) workers in the U.S. and 10 million elsewhere1 • Top-ranked company in Financial Data Services in FORTUNE® magazine’s The World’s Most Admired Companies3 • Forbes magazine —100 Most Innovative Companies4

Source: Automatic Data Processing LLC, 2013 Annual Report.

Source: Moody’s and Standard & Poor’s.

3 Source: FORTUNE® Magazine’s Most Admired Companies 2014.

4 Source: Forbes Magazine, August 2013.

1 2

GuidedSavings® is offered by GuidedChoice® Asset Management, Inc. GuidedSavings® is a registered trademark of GuidedChoice® Asset Management, Inc. None of ADP Broker-Dealer, Inc. nor any of its affiliates is an affiliate of, nor do any of them endorse, the services or products of GuidedChoice®.

Investment options are available through ADP Broker-Dealer, Inc., an affiliate of ADP, LLC, One ADP Blvd., Roseland, NJ 07068. Member FINRA. ADP, LLC and its affiliates do not offer investment, tax or legal advice and nothing contained in this communication is intended to be, nor should be construed as, advice or a recommendation for a particular investment option. Questions about how laws, regulations and guidance apply to a specific plan should be directed to your plan administrator or legal, tax or financial advisor.

1/2011-FN

ADP Broker-Dealer, Inc. One ADP Boulevard Roseland, NJ 07068 Member FINRA

For complete information about a particular fund or to obtain a fund prospectus (or information statement, in the case of commingled funds), go to www.mykplan.com or call the Voice-Response System. You should carefully consider an investment option’s objectives, risks, charges and expenses before investing. The prospectus (or information statement, as applicable) contains this and other important information about the investment option and investment company. Please read the prospectus/information statement carefully before you invest or send money.

The ADP Logo is a registered trademark of ADP, LLC. A more human resource. is a registered trademark of ADP, LLC. Save Smart is a registered trademark of ADP, LLC. All other trademarks and service marks are the property of their respective owners.

This book was printed on 30% Post-Consumer recycled fiber.

04-3012-1215

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ROLLOVER FORM - 280 How to Complete the Rollover Form

!

Rolling your previous retirement accounts into your current plan can protect savings from taxes and penalties, simplify your retirement planning, and may allow you to borrow from this money (if applicable).

When to use this form: This form is used to invest prior plan money into your current retirement plan. Generally, you can roll assets from these types of plans: Qualified Plans (Including 401(k) Plans), SIMPLE IRAs in existence for at least 2 years, Conduit and Traditional IRAs (taxable non-Roth distributions only), 457(b) plans, and 403(b) tax sheltered annuity contracts.

STEP 1 Verify with your employer that you are eligible to roll a prior account into your current plan.

Once you have confirmed eligibility, contact your prior plan or IRA provider to begin the rollover process. If you need assistance or have any questions, please call 1-877-401-5725.

STEP 2 Request a certified or bank check for your rollover.

The check should be payable to <<PayableTo>>.

RELIANCE TRUST COMPANY Include your Social Security number and Plan number 227842 <<PLID1>> on the check.

Once you have your rollover check, complete the remaining steps and submit for processing.

STEP 3 Section I - Participant Information Complete all the requested information in this section.

STEP 4 Section II - Rollover Source ■ Choose one rollover distribution source: Qualified Plan, IRA, 403(b), §457 or SIMPLE IRA (indicate the type of plan).

■ When making a Qualified plan rollover, indicate whether it is related or unrelated to the current plan: (Most rollovers are not related.) o No–Unrelated - rollover is from a previous employer plan. o Yes–Related - rollover is from another plan of your current employer plan.

Note: If you do not check a box, we will understand you have certified that the rollover is from an unrelated employer.

STEP 5 Section III - Rollover Type and Amount ■ Select the type of money you want to roll into the plan.

■ For Roth 401(k) rollover amounts: complete the Contribution + Earnings = Total amount sections. Please refer to the distribution statement provided by prior 401(k) provider for this information.

■ Indicate the date your Roth 401(k)contributions began. This date allows ADP to track your contribution for taxation purposes.

■ All information is required to complete your rollover.

STEP 6 Section IV - Participant Signatures and Acknowledgment ■ Read the Acknowledgement, sign and date the form at the bottom (participant signature).

STEP 7 Return to your Employer for the Plan Administrator’s signature or your form and funds will be returned ■ Give the completed form and check to your Plan Administrator to sign and submit for processing.

NOTE FOR PLAN ADMINISTRATORS: Review and approve the rollover distribution (see Plan Administration manual for information). The check should be payable to RELIANCE <<PayableTo>> TRUST COMPANY Include your Social Security number and Plan number <<PLID1>> on the check. Sign and date the form, 227842 attach the rollover check and send to: Overnight Mail Regular Mail ADP C/O FIS ADP NJ CRS Attention: Lockbox 13399 P.O. Box 13399 Lockbox Dept. 1st Floor Newark, NJ 07101-3399 400A Commerce Boulevard Carlstadt, NJ 07072 Incomplete forms or forms submitted without financial deposits/checks will be returned.

If you need assistance or have any questions, please call 1-877-401-5725.

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ROLLOVER FORM - 280

*280*

Section I Participant Information Social Security # _________________________________

Employee Name (Last) ___________________________________________ (First) ____________________________________ (Middle Initial) ____ Address (Street) ____________________________________________________________________ (Apt. # / PO Box#) _______________________ (City) ________________________________________________________________________ (State) _____ (Zip Code) _______________________ Birth Date _________________________________ Month/Date/Year

Hire Date _________________________________ Month/Date/Year

Email Address ______________________________________________________________

Phone # ___________________________________

How to Make the Check Payable A preprinted certified or bank check must accompany this form for the stated dollar amount. Handwritten checks will be returned to the Plan Administrator. Please include your Social Security Number and Plan Number <<PLID1>> RELIANCE TRUST COMPANY 227842 on the check made payable to <<PayableTo.>>

Section II Rollover Source This rollover is a distribution from: (Select one type of plan or account.) o Qualified Plan o §403(b) Tax Sheltered Annuity o §457 Plan o Individual Retirement Account o SIMPLE IRA (Must be in existence at least 2 years.)

If Qualified Plan, is this rollover from a related employer? (Most rollovers are unrelated.) o No Unrelated o Yes Related Note: If you do not check a box, we will understand you have certified that the rollover is from an unrelated employer.

Section III Rollover Type and Amount Select rollover type: o Before-Tax 401(k)

$______________________________ Total Rollover Amount

$________________ (Contributions) + $________________ (Earnings) = $________________ Total Rollover Amount o Roth 401(k) Date Roth 401(k) contributions began: (If not provided, ADP will use date contribution is received) ________ / ________ / 20___ Note: Rollovers of Roth 401(k) monies may only be made via direct rollover and may not be rolled over from an IRA. Please refer to the distribution statement provided by your prior 401(k) provider for this information.

Section IV Participant Acknowledgement, Rollover Investment Direction and Signature I have read and understand the Summary Plan Description, agree to the Plan provisions, received the Fee Disclosure Statement and reviewed and understand the fund prospectuses/descriptions, including the funds’ objectives, risks, expenses and charges. By signing this form, I certify that: • I am rolling over these funds within 60 days of the date I received them from an eligible employer plan or IRA (not applicable to direct rollovers).

• The rollover is from the source indicated and has not been combined with any money that would disqualify it.

• No portion of this rollover contribution represents amounts received as a hardship distribution from another employer plan.

I understand that if I do not have a plan account one will be established for my rollover contribution and invested in the plan default fund. Once my account has been established, I will be mailed my account access information and can make investment allocation changes through the plan website or Voice Response System. If I already have a plan account established, I direct that my rollover contribution be invested in accordance with my investment election on file.

Many investment companies have excessive trading and/or redemption fee policies for certain investments to eliminate or reduce the negative effects of short-term trading and market timing. When possible, ADP Retirement Services implements the investment company's market timing policy (as disclosed in the prospectus). However, in some circumstances ADP may impose a different policy than listed in the prospectus at the request or with the agreement of a fund company. Your plan investment options may be subject to these policies. See your plan website for your plan’s fund policies and additional information.

Signature of Employee/Participant

Date

Return to your Employer for the Plan Administrator’s signature or your form and funds will be returned.

Plan Administrator Approval/Signature:___________________________________ Date Received: ________________ <<PLID1>> 227842 Recordkeeping Plan #:____________________________

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Dear participant, Be sure to download the free ADP Mobile App today to access information for all your ADP-hosted accounts. And with the new tools released for retirement savings, you can take advantage of:

More Mobile Functionality Coming Soon!

Stay tuned for even more functionality, including the ability to change how future contributions are invested, options to receive personalized mobile notifications, and access to financial wellness information!

ASPEN 2018 BENEFITS :: 104

It’s Easy to Get Started using the ADP Mobile App.

• Download and install the ADP Mobile App from the Apple App Store®, Google Play®, Windows Phone Store®, or Amazon Appstore®.

• Login to your account: Enter your registered login ID and password

credentials, the same information used at www.mykplan.com and any additional ADP services.

• Obtain Login Credentials: If you do not have login credentials, please register at www.mykplan.com.

Download the free ADP Mobile App today.

*if Mobile is enabled for other ADP products, additional features will be displayed on the dashboard.

Minimum system requirements: The ADP mobile app is available on the following devices: iPhone®, iPad®, iPod touch® iOS v7.0 or higher, Android™ v4.4 or higher, or Windows Phone 8.0 or higher.

To ensure that you continue receiving our emails, please add us to your address book or safe list.

This is an automated email, please do not reply to this email. ADP, LLC and its affiliates (ADP) do not offer investment, financial, tax or legal advice or management services. For its retirement plan recordkeeping customers, ADP agrees to act as a non-discretionary recordkeeper performing ministerial functions at the direction of the plan sponsor and/or plan administrator. Accordingly, ADP does not serve in a fiduciary capacity to any of the retirement plans for which it provides recordkeeping services. ADP also does not serve as an investment advisor or manager to any of the retirement plans for which it provides recordkeeping services. Nothing in these materials is intended to be, nor should be construed as, advice or a recommendation for a particular situation or plan. Please consult with your own advisors for such advice.

This message and any attachments are intended only for the use of the addressee and may contain information that is privileged and confidential. If the reader of the message is not the intended recipient or an authorized representative of the intended recipient, you are hereby notified that any dissemination of this communication is strictly prohibited. If you have received this communication in error, notify the sender immediately by return email and delete the message and any attachments from your system.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP — A more human resource. is a service mark of ADP, LLC. All other trademarks and service marks are the property of their respective owners. © 2015–2016 ADP, LLC. All Rights Reserved.

This message was sent to you as our valuable customer because you provided your e-mail address to us previously.

If you wish to opt out from future mailings, please select the link below.

Opt Out of Future Mailings.

ADP Retirement Services | 71 Hanover Road | Florham Park, NJ | 07932

ASPEN 2018 BENEFITS :: 105

Hello Aspen Heights 401(k) Participants and Eligible Participants, ACTION ITEM: Please acknowledge receipt of these documents by electronically signing.

Other than signing to acknowledge receipt of this document, this communication is for your information only we advise you look over the attached fee information so you will be aware of them. There is no further action needed.

Employee Acknowledgement of 2017 401k Participant Fee Disclosure with electronic delivery authorization: ______________________________________________ Who Is Receiving This Communication Employees who are active Aspen Heights 401(k) plan participants or are eligible to participate in our plan but not currently participating.

Why You Are Receiving This Communication The U.S. Department of Labor requires us to disclose certain 401(k) plan fee and investment-related information annually. The Participant Disclosure regulation is designed to make it even easier for you to understand and review fees and expenses associated with your retirement plan account and to provide you with some important additional information about the plan.

Along with this communication, you will find an Annual Fee Disclosure Statement that provides information on the following: • General Plan Information • Plan Administrative Expenses • Individual Expenses Any actual fees deducted from your account will be reflected on your quarterly account statement and an updated disclosure statement will be provided annually.

Assistance in Understanding the New Fee Disclosures To learn more about the information contained in your statement, ADP Retirement Services has developed a number of useful tools, as follows: • Understanding Retirement Plan Fees brochure. This brochure provides an overview of the new retirement plan fee disclosures.

• Participant Fee Disclosure FAQ: A “Frequently Ask Questions” (FAQ) that provides answers to common participant fee-related questions.

This information, along with a copy of your disclosure statement, is available under "Plan Information">>"Plan Details and Disclosures" on the Plan Participant web site (www.mykplan.com) or further down in this document.

Additionally, a Glossary of Investment Terms, which includes definitions of terms found in the Disclosure Statement, can be viewed on the web site under "Investments">>"Investment Performance and Information".

All of this information will also be posted in the HR section of ThinkAspen.

Questions If you have any questions regarding the new disclosures or your disclosure statement, please call ADP's 401k Team at 800-695-7526. If you want a hard copy, print it out or let myself or your General Manager know.

Warm Regards,

Sarah Weiner | HR, Benefits, & Payroll Business Partner Aspen Heights | Austin Direct: 512.910.3266 | Fax: 512-879-1179 | Email: sweiner@ahpliving.com

ASPEN 2018 BENEFITS :: 106

PARTICIPANT FEE DISCLOSURE STATEMENT Aspen Heights 401(K) Plan ("Plan") August 31, 2017

This Disclosure Statement is provided by your employer to explain the costs associated with participating in the Plan. It is for informational purposes and is intended to help you make informed decisions about your investments. Unless specifically noted below, all information in this statement is provided as of the above date.

The document includes these sections: Highlights 1. General Plan Information 2. Plan Administrative Expenses 3. Individual Expenses 4. Comparative Chart of Plan Investment Options (“Comparative Chart”)

• This disclosure is provided for informational purposes. You should read this document carefully, but are not required to take any other specific action.

• This document explains the costs and fees that you may be charged for participating in your employer’s retirement plan.

• This document may be helpful when making decisions about your plan investments.

Special Note: No fees will be charged to you if you have no account balance in the plan.

If you are an Eligible Employee* and not participating, you can enroll at: www.mykplan.com or by calling the Participant Call Center. *Your plan may have certain age and length of service requirements that you must meet in order to participate. Since you received this notice, you may have become eligible and may already be participating in the plan. If you would like to confirm your eligibility under the plan, you may log on to the Participant Website or contact a Participant Call Center Representative.

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1. General Plan Information Giving investment instructions1 • To direct or change your Plan investments, you must either: i. make your investment elections on the Participant Website www.mykplan.com, or ii. speak with a Participant Call Center Representative at 1-800-695-7526.

•

You may direct the investment of all funds held in your Plan account.

Limitations on instructions. Your financial transactions that you request prior to 4:00 p.m. ET or the close of the NYSE, if earlier, on a business day are effective that day. Any financial transactions you request after that time will be treated as received, and will be processed, the next business day.

Designated investment options. Your Plan has a menu of investment options into which you can direct the investment of your plan funds. Generally, Plan investments are selected to provide a wide range of different asset classes (like stocks and bonds) as well as investment styles and managers. Since it is important to understand how these investment choices fit into your personal investment strategy, your company has provided extensive information on these investment choices through ADP’s Participant Website and the Participant Call Center. Please see the Comparative Chart section below for the names of, and information about, these designated investment options.

Voting and other rights. The Plan Sponsor will exercise any voting or other rights associated with ownership of shares or units of the designated investment options held in your plan account.

1

Your plan has employed ADP Retirement Services as your plan’s record keeper. ADP Retirement Services provides a comprehensive Participant Website to help you join the plan, initiate transactions or get more information. The participant website and toll free number are generally available 24 hours a day, 7 days a week except during periods of scheduled maintenance. In addition, the Participant Call Center Representatives are knowledgeable in your Plan’s provisions, operations and investment choices. Whether you are already in the Plan and need help with a question or you wish to enroll and begin contributing, the Participant Call Center Representative can help Monday through Friday during normal business hours.

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Designated investment manager. Guided Choice is a designated investment manager for the assets managed in accordance with the managed accounts product offered by Guided Choice.

2. Plan Administrative Expenses.

Plan administrative expenses, for services such as legal, consulting, audit, accounting, trustee, investment management and advice, and record keeping services, may be incurred to administer the plan. These expenses of administering the Plan may be paid by your employer or from the Plan, or both.

Administrative expenses that are not paid by the employer may be deducted from your account. The actual expenses deducted from your account, if any, will be reflected on your quarterly account statement and on the Participant Website at www.mykplan.com. Your employer is currently invoiced for administrative fees charged by the Planâ&#x20AC;&#x2122;s recordkeeper or collected by the recordkeeper on behalf of another service provider. Additional disclosure will be provided to you if fees will be taken from participantsâ&#x20AC;&#x2122; accounts.

In addition to any Plan administrative expenses described above, fees for Investment related services to the Plan of 0.25% of participant balances will be allocated pro rata based on participant account balances to participant accounts. A portion of this fee will be charged to participant accounts quarterly.

Please see the online glossary on the Participant Website www.mykplan.com for a definition of pro rata allocation and an example of how a pro rata allocation applies, or contact the Participant Call Center.

Additional disclosure will be provided to participants if other Plan administrative fees will be charged to participant accounts.

3. Individual Expenses.

The Plan will apply the following charges directly to your account, if applicable: Transaction/Service

Fee

Final Distribution

$50.00 per distribution

Withdrawal

$50.00 per withdrawal

Loan Initiation

$125.00 processing fee per Loan set-up

GuidedChoice Managed Accounts

0.20% investment management fee charged by Guided Choice.

0.15% administrative services fee charged by ADP. This is an annual fee charged to your account monthly.

Buy/Sell Investments

Buying or selling some investments may result in individual account charges specific to those investments, such as redemption fees. See the Comparative Chart below for details.

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4. Comparative Chart Investment Options – August 31, 2017 The Comparative Chart section includes important information to help you compare the investment options in your retirement plan, including performance information, fees and expenses.

Additional investment information such as the investments; objectives, strategies and portfolio turnover rate can be found at ADP’s Participant website www.mykplan.com on the “Investment Performance and Information” page. You may also contact the ADP Participant Call Center at 1-800-695-7526 , ADP Retirement Services, 71 Hanover Road, MS 3333, Florham Park, NJ, 07932 to request additional investment information or a paper copy of the information available on the web site.

Variable Performance Investment Comparative Chart2 The Comparative Chart below includes performance of investment options that do not have a fixed or stated rate of return. It shows: • Average Annual total Return3 - Investment option performance over time as compared to an appropriate benchmark4 for the same time period, • Total Annual Operating Expenses -The actual cost to you for investing in a fund is the Net Expense Ratio amount. The impact of that expense is already included in the Average Annual Total Return displayed.

• Shareholder type Charges and Investment Restrictions – are investment related fees not reflected in Total Annual Operating Expenses, and fund specific investment restrictions.

Past performance is no guarantee of future results. Your investment in these options could lose money. Current performance may be lower or higher than the performance data quoted. The most recent performance and information about risks is available at www.mykplan.com on the “Investment Performance and Information” page.

________________________________________ 2

Please note that this chart presents certain information about investments in the Plan. The information may differ in content (for example, the time periods over which performance is calculated) or in format from other material provided to you in written communications, on the Participant Website or in other websites or publications.

3 Average Annual Total Return is a measure of the average return of an investment over some historical period, such as 5 or 10 years. These returns are reported after adjusting for the fund’s operating expenses, or Net Expense Ratio, but do not include any sales charges or brokerage commissions incurred in managing the fund.

4 In order to evaluate an investment fund’s performance, it is sometimes helpful to compare that fund’s returns for the same period against the return of the market from which the fund is choosing its investments. Certain independent companies publish Benchmarks, such as the Standard & Poor’s 500, which are meant to approximate the return of all of the investments in that market. Each fund compares its returns against the Benchmark they feel most appropriately represents the market in which they are investing that fund’s assets.

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Name/ Type of Option

Average Annual Total Return as of 06/30/17

Total Annual Operating Expenses

Shareholder - Type Charges and Investment Restrictions

Net Expense Ratio

Net per $1000

Gross Expense Ratio

Gross per $1000

1yr.

5yr.

10yr.

Since Inception

Invesco Stable Asset Fund - ADPZ Class/ Stable Value

1.69%

N/A

N/A

1.55%

0.45%

$4.50

0.45%

$4.50

Benchmark – USTREAS T-Bill Cnst Mat Rate 3 Yr

-1.20%

0.19%

2.14%

0.48%

N/A

N/A

N/A

N/A

JPMorgan Core Plus Bond Fund Class R6/ Intermediate-Term Bond

1.35%

3.48%

5.52%

5.15%

0.40%

$4.00

0.43%

$4.30

Benchmark – Barclays US Agg Bond TR USD

-0.31%

2.21%

4.48%

4.22%

N/A

N/A

N/A

N/A

Vanguard Intermediate Term Bond Index Fund - Admiral Class/ Intermediate-Term Bond

-0.97%

2.64%

5.62%

5.20%

0.07%

$0.70

0.07%

$0.70

Benchmark – Barclays US Agg Bond TR USD

-0.31%

2.21%

4.48%

4.41%

N/A

N/A

N/A

N/A

BlackRock High Yield Bond Portfolio - Class K/ High Yield Bond

12.79%

7.15%

7.35%

7.64%

0.53%

$5.30

0.54%

$5.40

Benchmark – BofAML US HY Master II TR USD

12.75%

6.91%

7.54%

6.97%

N/A

N/A

N/A

N/A

DFA Inflation Protected Securities Portfolio - Institutional Class/ Inflation-Protected Bond

-0.89%

0.22%

4.51%

4.27%

0.12%

$1.20

0.12%

$1.20

Benchmark – BarCap US Treasury US TIPS TR USD

-0.63%

0.27%

4.27%

4.11%

N/A

N/A

N/A

N/A

Vanguard Target Retirement Income Fund - Investor Class/ Target-Date

5.23%

4.91%

4.97%

5.28%

0.13%

$1.30

0.13%

$1.30

Benchmark – Morningstar Lifetime Moderate Income

4.93%

4.64%

4.76%

5.87%

N/A

N/A

N/A

N/A

You are allowed 1 transfers in and out of the fund within 60 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

You are allowed 2 transfers in and out of the fund within 30 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

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Name/ Type of Option

Average Annual Total Return as of 06/30/17

1yr.

5yr.

10yr.

Total Annual Operating Expenses

Since Inception

Net Expense Ratio

Net per $1000

Gross Expense Ratio

Shareholder - Type Charges and Investment Restrictions Gross per $1000

Vanguard Target Retirement 2015 Fund - Investor Class/ Target-Date

8.13%

7.27%

4.86%

6.19%

0.14%

$1.40

0.14%

$1.40

Benchmark – Morningstar Lifetime Moderate 2015

6.76%

6.40%

5.05%

7.18%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2020 Fund - Investor Class/ Target-Date

10.30%

8.40%

5.07%

6.22%

0.14%

$1.40

0.14%

$1.40

Benchmark – Morningstar Lifetime Moderate 2020

7.98%

7.28%

5.04%

6.21%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2025 Fund - Investor Class/ Target-Date

11.95%

9.17%

5.10%

6.74%

0.14%

$1.40

0.14%

$1.40

Benchmark – Morningstar Lifetime Moderate 2025

9.75%

8.35%

5.09%

7.95%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2030 Fund - Investor Class/ Target-Date

13.40%

9.90%

5.10%

6.49%

0.15%

$1.50

0.15%

$1.50

Benchmark – Morningstar Lifetime Moderate 2030

11.98%

9.42%

5.21%

6.63%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2035 Fund - Investor Class/ Target-Date

14.99%

10.63%

5.25%

7.34%

0.15%

$1.50

0.15%

$1.50

Benchmark – Morningstar Lifetime Moderate 2035

14.13%

10.19%

5.36%

8.50%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2040 Fund - Investor Class/ Target-Date

16.49%

11.10%

5.50%

6.84%

0.16%

$1.60

0.16%

$1.60

Benchmark – Morningstar Lifetime Moderate 2040

15.58%

10.53%

5.44%

6.93%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2045 Fund - Investor Class/ Target-Date

17.02%

11.18%

5.52%

7.77%

0.16%

$1.60

0.16%

$1.60

Benchmark – Morningstar Lifetime Moderate 2045

16.22%

10.57%

5.41%

8.68%

N/A

N/A

N/A

N/A

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

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Name/ Type of Option

Average Annual Total Return as of 06/30/17

1yr.

5yr.

10yr.

Total Annual Operating Expenses

Since Inception

Net Expense Ratio

Net per $1000

Gross Expense Ratio

Shareholder - Type Charges and Investment Restrictions Gross per $1000

Vanguard Target Retirement 2050 Fund - Investor Class/ Target-Date

16.99%

11.18%

5.52%

6.92%

0.16%

$1.60

0.16%

$1.60

Benchmark – Morningstar Lifetime Moderate 2050

16.41%

10.50%

5.36%

6.90%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2055 Fund - Investor Class/ Target-Date

16.99%

11.15%

N/A

10.96%

0.16%

$1.60

0.16%

$1.60

Benchmark – Morningstar Lifetime Moderate 2055

16.50%

10.40%

5.28%

10.23%

N/A

N/A

N/A

N/A

Vanguard Target Retirement 2060 Fund - Investor Class/ Target-Date

17.00%

11.17%

N/A

10.71%

0.16%

$1.60

0.16%

$1.60

Benchmark –

16.54%

10.27%

5.31%

9.73%

N/A

N/A

N/A

N/A

Columbia Balanced Fund - Class Y/ Risk Based

10.89%

N/A

N/A

10.86%

0.66%

$6.60

0.66%

$6.60

Benchmark – Morningstar Moderate Target Risk

10.95%

7.74%

5.31%

7.60%

N/A

N/A

N/A

N/A

Vanguard Wellesley Income Fund - Admiral Class/ Risk Based

5.04%

7.22%

6.91%

7.00%

0.15%

$1.50

0.15%

$1.50

Benchmark – Morningstar Moderately Cons Target Risk

7.15%

5.74%

4.91%

5.70%

N/A

N/A

N/A

N/A

American Beacon Bridgeway Large Cap Value Fund Institutional Shares/ Large Value

15.07%

15.37%

7.14%

9.60%

0.73%

$7.30

0.73%

$7.30

Benchmark – Russell 1000 Value TR USD

15.53%

13.94%

5.57%

8.36%

N/A

N/A

N/A

N/A

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

You are allowed 1 transfers in and out of the fund within 30 days. Once you reach this restriction you will be blocked from future transfers into this fund for 30 days.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

You are allowed 1 transfers in and out of the fund within 90 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

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Name/ Type of Option

Average Annual Total Return as of 06/30/17

1yr.

5yr.

10yr.

Total Annual Operating Expenses

Since Inception

Net Expense Ratio

Net per $1000

Gross Expense Ratio

Shareholder - Type Charges and Investment Restrictions Gross per $1000

DFA US Core Equity 1 Portfolio Institutional Class/ Large Blend

19.65%

14.78%

7.29%

8.37%

0.19%

$1.90

0.19%

$1.90

Benchmark – Russell 1000 TR USD

18.03%

14.67%

7.29%

8.30%

N/A

N/A

N/A

N/A

Vanguard Dividend Growth Fund Investor Class/ Large Blend

11.95%

13.13%

8.08%

8.37%

0.30%

$3.00

0.30%

$3.00

Benchmark – Russell 1000 TR USD

18.03%

14.67%

7.29%

9.66%

N/A

N/A

N/A

N/A

Alger Spectra Fund - Class Z/ Large Growth

21.31%

15.38%

N/A

13.43%

0.89%

$8.90

0.99%

$9.90

Benchmark – Russell 1000 Growth TR USD

20.42%

15.30%

8.91%

13.64%

N/A

N/A

N/A

N/A

American Beacon Mid Cap Value Fund - Institutional Class Shares/ Mid-Cap Value

24.49%

14.80%

7.44%

8.79%

0.90%

$9.00

0.90%

$9.00

Benchmark – Russell Mid Cap Value TR USD

15.93%

15.14%

7.23%

8.79%

N/A

N/A

N/A

N/A

Vanguard Extended Market Index Fund - Admiral Class/ Mid-Cap Blend

21.61%

14.34%

7.72%

7.91%

0.08%

$0.80

0.08%

$0.80

Benchmark – Russell Mid Cap TR USD

16.48%

14.72%

7.67%

8.85%

N/A

N/A

N/A

N/A

Dreyfus/The Boston Company Small/Mid Cap Growth Fund Class Y/ Mid-Cap Growth

20.60%

N/A

N/A

11.11%

0.68%

$6.80

0.68%

$6.80

Benchmark – Russell Mid Cap Growth TR USD

17.05%

14.19%

7.87%

11.80%

N/A

N/A

N/A

N/A

You are allowed 2 transfers in and out of the fund within 30 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

You are allowed 1 transfers in and out of the fund within 90 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

You are allowed 4 transfers in and out of the fund within 365 days. Once you reach this restriction you will be blocked from future transfers into this fund for 365 days.

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Name/ Type of Option

Average Annual Total Return as of 06/30/17

1yr.

5yr.

10yr.

Total Annual Operating Expenses

Since Inception

Net Expense Ratio

Net per $1000

Gross Expense Ratio

Shareholder - Type Charges and Investment Restrictions Gross per $1000

Victory Integrity Small-Cap Value Fund - Class R6/ Small Value

23.40%

14.19%

N/A

15.68%

1.00%

$10.00

1.00%

$10.00

Benchmark – Russell 2000 Value TR USD

24.86%

13.39%

5.92%

14.89%

N/A

N/A

N/A

N/A

DFA US Small Cap Portfolio Institutional Class/ Small Blend

21.56%

14.61%

7.95%

10.63%

0.37%

$3.70

0.37%

$3.70

Benchmark – Russell 2000 TR USD

24.60%

13.70%

6.92%

9.37%

N/A

N/A

N/A

N/A

JPMorgan US Small Company Fund - Class R6/ Small Blend

20.64%

14.93%

N/A

15.84%

0.74%

$7.40

0.75%

$7.50

Benchmark – Russell 2000 TR USD

24.60%

13.70%

6.92%

14.45%

N/A

N/A

N/A

N/A

Janus Henderson Venture Fund Class N/ Small Growth

21.00%

14.69%

N/A

15.28%

0.68%

$6.80

0.68%

$6.80

Benchmark – Russell 2000 Growth TR USD

24.40%

13.98%

7.82%

14.88%

N/A

N/A

N/A

N/A

American Beacon International Equity Fund - Institutional Class Shares/ Foreign Large Value

19.17%

8.44%

1.34%

7.32%

0.70%

$7.00

0.70%

$7.00

Benchmark – MSCI ACWI Ex USA Value NR USD

23.62%

6.35%

0.31%

N/A

N/A

N/A

N/A

N/A

You are allowed 2 transfers in and out of the fund within 90 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

You are allowed 2 transfers in and out of the fund within 30 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

You are allowed 1 transfers in and out of the fund within 60 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

You are allowed 1 transfers in and out of the fund within 90 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

ASPEN 2018 BENEFITS :: 115

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Name/ Type of Option

Average Annual Total Return as of 06/30/17

1yr.

5yr.

10yr.

Total Annual Operating Expenses

Since Inception

Net Expense Ratio

Net per $1000

Gross Expense Ratio

Shareholder - Type Charges and Investment Restrictions Gross per $1000

DFA Large Cap International Portfolio - Institutional Class/ Foreign Large Blend

20.06%

8.31%

1.32%

5.73%

0.23%

$2.30

0.23%

$2.30

Benchmark – MSCI AC World Ex USA NR USD

20.45%

7.22%

1.13%

N/A

N/A

N/A

N/A

N/A

Oppenheimer International Growth Fund - Class I/ Foreign Large Growth

16.44%

9.74%

N/A

8.02%

0.70%

$7.00

0.70%

$7.00

Benchmark – MSCI ACWI Ex USA Growth NR USD - Foreign Large Growth

17.38%

8.04%

1.89%

6.22%

N/A

N/A

N/A

N/A

Columbia Emerging Markets Fund - Class Y/ Diversified Emerging Mkts

23.21%

N/A

N/A

4.46%

1.19%

$11.90

1.22%

$12.20

Benchmark – MSCI EM NR USD

23.75%

3.96%

1.91%

2.74%

N/A

N/A

N/A

N/A

Vanguard REIT Index Fund Admiral Class/ Real Estate

-1.93%

9.28%

6.18%

10.92%

0.12%

$1.20

0.12%

$1.20

Benchmark – S&P United States REIT TR USD

-2.25%

9.23%

5.78%

10.82%

N/A

N/A

N/A

N/A

You are allowed 2 transfers in and out of the fund within 30 days. Once you reach this restriction you will be blocked from future transfers into this fund for 90 days.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

You are allowed 1 transfers in and out of the fund within 30 days. Once you reach this restriction you will be blocked from future transfers into this fund for 30 days.

Transfers into this fund are not permitted for 30 days after you transfer out of the fund.

The Net Expense Ratio is the fund’s "Total Expense Ratio (Gross)" reduced for any investment management fee waivers that are currently in effect.

The Gross Expense Ratio is the fund's total expense ratio which is defined as the total cost of investing and administering assets, including management fees, 12b-1 fee (if applicable) in a mutual fund or other collective fund expressed as a percentage of total assets.

The Per $1,000 Total Annual Operating Expenses listed in the table above is the total annual operating expenses of the investment for a one-year period expressed as a dollar amount for a $1,000 investment, assuming no returns and based on the stated percentage.

Fees and expenses are only one of several factors that you should consider when making investment decisions. The cumulative effect of fees and expenses may substantially reduce the growth of your retirement account. For more information about fees and expenses, visit the Department of Labor’s web site at http://www.dol.gov/ebsa/publications/401k_employee.html.

ASPEN 2018 BENEFITS :: 116

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For a glossary of investment terms, log in to your account at www.mykplan.com, select “Investments”, then go to the Investment Performance and Information page and click on the "Glossary of Investment Terms" link.

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Retirement Services

Fees and Expenses Understanding Retirement Plan Fees

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Other Items to Consider

Your Plan Administrator will soon provide you with a Participant Fee Disclosure Statement that summarizes the fees and expenses that may apply to you when participating in your retirement plan.

Important Considerations When Choosing Investments Information about plan fees and expenses is important and there is a great deal of information available to you. However, remember that when making decisions about saving and investing for retirement there is more to consider than just fees. You should also take into account other factors like the historical performance of an investment option and its investment objectives, strategies and risks. Your individual situation, your risk tolerance (which is your ability and willingness to lose some or all of an investment in exchange for greater potential returns), your time horizon, and the other financial resources you may have outside of the plan should also be a part of your personal retirement plan.

ADDITIONAL INFORMATION Available on your plan website: TT

TT TT

TT

erformance, fact sheets and other general P information about the investment options in your plan Fund prospectuses or information statements I nvestment and financial education materials and tools Glossary of terms

You can also see your Plan Administrator for additional information about retirement plan fees and expenses.

This information is intended to provide general financial investment and retirement information and should not be construed as investment advice.

For complete information about a particular fund, please read the fund prospectus (or information statement, in the case of commingled funds). You should carefully consider an investment option’s objectives, risks, charges and expenses before investing. The prospectus (or information statement, as applicable) contains this and other important information about the investment option and investment company. Please read the prospectus/information statement carefully before you invest or send money.

1 ASPEN 2018 BENEFITS :: 119

Fees and Expenses

Soon, you will receive a Participant Fee Disclosure Statement from your employer that summarizes the fees that may be applicable to you as a participant in your retirement plan.

Understanding these fees can help you make informed decisions about your retirement planning. Fees and expenses are a part of every retirement plan. Keep in mind that saving for your future financial security is important and fees are just one of many factors to consider when making decisions about saving and investing for your retirement.

Types of Fees and Expenses There are primarily three types of fees and expenses: administrative, individual, and investment related fees.

Some may be paid by your employer and others you will be responsible for paying.

Administrative expenses These expenses are charges for services that are necessary to operate the plan. Record keeping, legal, accounting and trustee services are considered administrative expenses.

These fees may be paid by your employer or charged to the plan. If they are charged to the plan they may be shared among and paid by all of the participants in the plan. These fees, if applicable to you, would be reflected on your quarterly account statement.

2

ASPEN 2018 BENEFITS :: 120

Individual expenses This expense type includes charges for services that are specific to transactions you have requested as a participant.

Some examples include plan loan fee, or charges for a final distribution or withdrawal.

These are transaction and service-based fees charged only if you elect to use a service or feature where a fee would apply. For example, if your plan offers loans and you take one, the loan fee would be deducted from your account.

These fees are deducted directly from your account.

Investment related expenses These expenses are charges for the investment management and the operation of the investment options that are available under the plan. There are primarily three types of investment expenses: Operating expense. This is the annual cost for operating and managing a specific investment option, and is often referred to as the fund “expense ratio”. This expense is not charged separately to participant accounts but instead it reduces the investment return that investors may receive from a fund. These types of expenses are common whether you are investing through a retirement plan or outside of a plan. Expense ratios are often calculated as gross and net expense ratio: TT

TT

ross expense ratio. The gross expense ratio represents an investment option’s total operating cost before G any fee waivers or reimbursements have been deducted. When applicable, fee waivers will reduce the actual cost of investing in the fund. et expense ratio. The net expense ratio is the gross expense ratio reduced by any fee waivers that may be in effect.

N This represents the actual cost to invest in a fund.

Gross Expense Ratio

-

Fee Waivers or Reimbursements

=

NET EXPENSE RATIO

ASPEN 2018 BENEFITS :: 121

Expense ratios are reported as percentages and may also be shown as a dollar cost per $1,000 invested.

For example, an investment option with a net expense ratio of 1.10% has an annual cost of $11 per $1,000 invested.

EXAMPLE OF ANNUAL FEES CHARGED TO A HYPOTHETICAL ACCOUNT:

You can find fund expense ratios on the plan performance summary that was provided at an enrollment meeting, on your account statement and on the participant website.

Fund operating expenses can vary widely depending on the type of investment product and investment manager, so be sure to review this expense information carefully when choosing your investments. Generally, investment products that require significant investment management will likely charge higher fees.

Total Account Assets....................... $20,000

Redemption fees. To discourage short term trading and market timing, many firms have established excessive trading and/or redemption fee policies for certain investments. For example, some investment options may require you to hold shares for a minimum amount of time, such as 90 days, and some may also restrict how often you can buy and sell shares within a certain period of time.

For these investments, a redemption fee may be charged when an investment is sold or redeemed. Generally, this fee is charged directly to the your account and typically is a percentage of the assets that were sold. The investment options available in your plan may or may not charge redemption fees. If these fees are applied to your account, they will appear on your quarterly account statement.

Loan Setup Fee for Loan Taken This Year ............................... =

$125

Total Fees and Expenses Charged to this Account for the Year:............

$379

Account Balance in Fund 1.............. $20,000 Fund 1 Expense Ratio...................... 1.27% Total Annual Investment Related Expenses............................ = ($20,000 x .0127)

$254

This is a hypothetical illustration and does not reflect any specific account, plan or investment option. Calculation assumes a constant balance of $20,000 on each day of the year (i.e., no investment gains or losses).

Actual expenses charged against an investment fund will vary based on the daily balance in the fund. For information about the specific fees and expenses that may apply to your plan, see the Participant Fee Disclosure Statement provided by your Plan Administrator.

Shareholder-type fees. This type of fee may include commissions, sales loads, surrender charges and exchange fees. They are charged directly against your investment and are not included in the fund’s annual operating expenses. The investment options available in your plan may or may not charge these types of fees.

Generally, shareholder-type fees will not apply to your plan account.

4 ASPEN 2018 BENEFITS :: 122

ADP Retirement Services 71 Hanover Road Florham Park, NJ 07932

You can make changes to your account on your plan website.

ADP, LLC and its affiliates do not offer investment, tax or legal advice to individuals. Nothing contained in this communication is intended to be, nor should be construed as, particularized advice or a recommendation for a particular investment option or course of action. Questions about how laws, regulations and guidance apply to your plan or account should be directed to your plan administrator or legal, tax or financial advisor.

ADP and the ADP logo are registered trademarks of ADP, LLC. ADP A more human resource. is a service mark of ADP, LLC. All other trademarks and service marks are the property of their respective owners.

99-2775-0617 Printed in USA Š 2011-2017 ADP, LLC. ALL RIGHTS RESERVED.

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ADP Fee Disclosure Plan Participant FAQ U.S. Department of Labor regulations related to company-sponsored retirement plans require retirement plan administrators (typically the company offering the retirement plan) to disclose detailed information to “eligible plan participants” (that is, eligible non-participating employees and active participants with an account balance) about plan fees, expenses, and investment options. In doing so, plan participants are then potentially better prepared to make informed decisions about their retirement plan account. Below are some frequently asked questions related to the disclosures.

Question

Answer

Why did I receive a participant fee disclosure statement?

The disclosure statement is required to be provided to you by the plan administrator and is for informational purposes. You should read the document, but you are not required to take any action. But if you are not currently participating in the plan, please consider enrolling (see below).

What is the participant fee disclosure statement?

The document explains the costs and fees that you may be charged for participating in your employer’s retirement plan. It also has information about your plan’s investments and other information about your plan.

Do I need to do anything?

No. The document is provided for informational purposes only.

I don’t participate in my company’s retirement plan. Is the plan costing me anything?

No. If you do not participate in the plan no fees will be charged to you.

However if you rolled money into the plan or maintain a balance in the plan— even though you may not be actively making contributions to the plan—you could be subject to plan administrative expenses, individual expenses and investment related expenses.

How can I participate in the plan?

If you are eligible to enroll in the plan, you can enroll right now at www.mykplan.com. Use the User ID and Password that was mailed to you to access the site.

What other information is available to me?

Further information about the investment options designated by your employer, such as fund performance, is available on www.mykplan.com. Some of this information is in addition to previously available information. Use the User ID and Password that was mailed to you to access the site.

ADP, LLC and its affiliates do not offer investment, tax or legal advice to individuals. Nothing contained in this communication is intended to be, nor should be construed as, particularized advice or a recommendation for a particular investment option or course of action. Questions about how laws, regulations and guidance apply to your plan or account should be directed to your plan administrator or legal, tax or financial advisor.

ADP, the ADP Logo are registered trademarks of ADP, LLC. ADP A more human resource. is a service mark of ADP, LLC. All other trademarks and service marks are the property of their respective owners.

99-2904-0617 Printed in USA Copyright © 2012-2017 ADP, LLC. ALL RIGHTS RESERVED.

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Recommended 401(k) Action Items: Access your 401(k) through ADP (https://workforcenow.adp.com) > Myself > Benefits > Retirement Savings or www.mykplan.com.

1. Unfortunately the beneficiaries you enter in ADP for your life insurance do not transfer over to your 401(k) so you need to enter beneficiaries for your 401(k) plan. The beneficiaries you should enter are the people that you want your 401(k) to go to in the event of your death.

TO ADD/EDIT BENEFICIARIES FOR YOUR 401(k):  log in to the 401(k) website at www.mykplan.com  click My Account > Manage My Beneficiaries  click Add New Beneficiary  add your Primary Beneficiary (you can have more than one but the percentage needs to add to 100%)  add Secondary Beneficiaries (these would be who would get the money if your primary beneficiaries are no longer alive)  click SAVE after you have added your beneficiaries.

Please go do that now – it only takes a few seconds. If you don’t have someone’s social security information, at least enter their names and all other information you do have at this time.

2. While you are in the 401(k) system, check to make sure you are contributing at least 6% total (to your Traditional 401(k), your Roth 401(k), or any mix of both) so that you can get your full 3% company match!

Don’t leave free money on the table! This is like a 3% raise that you can give yourself!

To Change Your 401(k) Payroll Deduction:  log in to the 401(k) website at www.mykplan.com  hover your mouse over “Contributions” in the top grey horizontal navigation bar  click “Change My Contribution Amount”  update your percentage so it totals at least 6%  click “Submit” 3. Lastly, your personal cell phone number and personal email address do not transfer from the ADP payroll system to the 401(k) system.

To Add Your Personal Email Address and Cell Number to Your 401(k):  log in to the 401(k) website at www.mykplan.com  hover over “My Profile” in the upper right corner of the screen  click “Contact Settings” 4. If you have completed the above 3 tasks, CONGRATULATIONS, you have leveled up your 401(k) skill!

Questions?

If you have any questions about how to do any of this, or anything else regarding your 401(k), contact ADP’s 401(k) Service Team at 800-695-7526.

ASPEN 2018 BENEFITS :: 125

The LifeCare web site

Voluntary and confidential

The LifeCare web site offers rich content, extensive search features, and a variety of interactive tools including LifeMart, an online Discount Center.

Highlights include:

LifeCare’s services are voluntary and confidential.

Over the years, employees have found our services to be an invaluable source of support and information.

We hope that you, too, will benefit from LifeCare.

Online provider searches and matches Instantly access information on providers and resources (child care, adult care, schools, fitness centers, etc.) nationwide Request personalized matches from a specialist via our interactive forms Confidentially view and retrieve information and matches via your own Message Center Access a history of your requests and transactions via your Account Activity section Best-in-class content Read or download our extensive library of materials available in printable html, PDF, and hard copy, including: Parenting information from experts Extensive content for seniors and caregivers on aging issues State regulations on child care centers and family day care homes nationwide Health content including a A-Z index of health articles, a Drug Database, a Symptom Checker, a Diagnosis Lookup Consumer articles on everyday issues such as choosing cleaning services, personal safety and home improvement

Life is

Challenging

Access LifeCare Today!

Call toll-free – 24 hours a day:  1-800-697-7315  For TDD/TTY service, call 1-800-873-1322 Access the LifeCare website via your employer’s ADP web portal:  Navigate to the “My Tools” page and select the LifeCare – Work/Life, EAP, Discounts link  Register by completing the simple, one-time process Once registered, two options are available to access LifeCare:  Visit the employer’s web portal OR visit directly via http://member.lifecare.com

Whatever life throws at you, can help.

Child Care and Paren ting Senior Ca re and Ag ing Legal and Financial Health an

d Wellness

A final note Neither LifeCare specialists nor the LifeCare web site are intended to provide any user with specific authority, advice or recommendations.

The information obtained through specialist assistance or the LifeCare web site is for informational purposes only. In all instances, users should verify all information received. All final decisions on the appropriateness of information, the quality of a product, or the qualifications of a service provider must be made by the user.

Interactive tools and features Medical animations that illustrate human anatomy, medical conditions and other scientific topics. Interactive quizzes on topics such as anger, anxiety, depression, lifestyle, patience, selfesteem and more Webinars, podcasts and audio tips

Discount vendors shown here and on our web site are subject to change without notice to you. We do not guarantee the inclusion of any particular discount or vendor on our site. We do not guarantee product availability or that the prices offered are the lowest available. LifeCare makes no warranties, express or implied, regarding the products or services offered through the discount center.

Access brand-name discounts too! Click the “LifeMart Discounts” tab on the LifeCare site to start saving today.

Find deals on computers, theme parks, movie tickets, DVDs, fitness centers, travel, jewelry, apparel, and more!

2 Armstrong Road, Shelton, CT 06484 800-697-7315  www.lifecare.com

Employee

Assistance Progra

m

Daily Nee

ds

LifeMart ®

ADP_CMBP_Flip_DC_09-031214 Copyright © 2014 ADP, Inc. ADP and the ADP logo are registered trademarks of ADP, Inc. In the business of your success is a registered service mark of ADP, Inc. LifeCare,® Inc. All rights reserved.

ASPEN 2018 BENEFITS :: 126

Need help managing work and life?

Take advantage of LifeCare®— an employer-paid benefit designed to save you time and relieve stress!

Trying to manage daily responsibilities and life events can be a real challenge at times.

Fortunately, there’s LifeCare, provided by your employer.

Offering comprehensive work and life services, LifeCare gives you the valuable and timely information you need to manage your daily life— from prenatal information to adult care . . . from summer camps to child care services . . . from pet care to health and wellness . . . and much more.

Plus, LifeCare offers LifeMart®, an online Discount Center that gives you exclusive access to discounts of up to 40 percent on over four million products and services.

Assistance around the clock Whenever you need assistance with a work and life issue—or a referral to a provider—LifeCare is always there for you, 24 hours a day, seven days a week. You can take advantage of LifeCare’s services by: Calling our toll-free phone number:

800-697-7315 or Visiting our web site:

How LifeCare can help you

Whether you access our services via telephone or the web, you will receive personalized information and matches 24 hours a day, seven days a week.

Child Care & Parenting Adoption Before- and after-school Breastfeeding

Child care (centers, in-home, family day care) Child development

Mothers at Work®

Special needs

Parenting infants to teens

Temporary/back up care

Prenatal care

Work & family

In-home services

Respite care

Legal and financial issues

Senior health and safety

Senior Care & Aging Care options and living arrangements

Geriatric care management

Caregiver issues and concerns

Home meal delivery programs (e.g. Meals on Wheels)

Hospice services

Transportation services

Medicare, Medicaid and Social Security

Legal & Financial Credit & debt

Legal

Personal finance

Retirement planning

Insurance

Medicare/Medicaid

Real estate & loans

Social Security

Plus, you may be eligible to receive FREE consultations with attorneys and financial counselors!

Health & Wellness Children’s health

Fitness/exercise

Men’s health

Senior health

Diet & nutrition

General health

Safety

Women’s health

Emotional health

Emotional Health/Employee Assistance Program (EAP) Anxiety

Domestic violence

Mental health

Stress

Conflict at work

Family issues

Personal issues

Substance abuse

Depression

Grief

Relationship issues

Call today for 3 face-to-face counseling sessions per issue with unlimited issues per year.

Daily Needs Automotive services

Home improvement

Pet care

Consumer information

Moving/relocation

Travel

Computers and electronics

Flights, cruises, car rentals, and hotels

Books and DVDs

Theme parks

Gifts and retail shopping

Utilities/home services

www.lifecare.com

LifeMart® Child and elder care products and services

Movie tickets and video rentals ASPEN 2018 BENEFITS :: 127

Frequently Asked Questions Q What is LifeCare? is a benefit, provided to you at no cost, that saves members time and A LifeCare money with quality matches to content, providers, products and services in parenting, senior care, legal and financial services, home services, wellness and EAP. LifeCare also operates LifeMart, one of the largest members-only online discounts shopping websites, with discounts of up to 40% on more than 4 million products and services.

Q How do I access LifeCare service? a LifeCare specialist call 800-697-7315 (or TDD/TTY 800-873-1322) or you A Tocanreach access LifeCare on the web by visiting your employer’s web portal Q What are LifeCare’s hours? experienced and helpful specialists are here to help with life’s most important A Our needs 24/7, 365 days a year.

Q What can LifeCare do for me? services are designed to help you and all members of your household A LifeCare’s balance work, life and personal issues.

• EAP services feature access to counseling by Master’s level clinicians and referrals to community services.

• The Child Care and Parenting services feature support for you and your family with referrals to child care options; adoption resources; prenatal and breastfeeding programs; education and recreational programs and help when it comes to planning for your children’s education.

• The Senior Care services feature support for you and your family with referrals to senior housing options; home care and home safety resources, retirement planning resources and help when it comes to addressing caregiver issues and concerns.

• The Legal and Financial services feature support for you and your family with referrals to legal counsel; financial planners; financial counselors to assist with debit or credit management and resources to help with legal document preparation and estate planning.

• The Home and Personal Service resources feature support for you and your family with referrals to contractors and home repair specialists; pet care resources; referrals to community resources and help when moving or relocating.

• LifeMart is a private online marketplace made available to employees by their employers. LifeMart features millions of discounts on leading brands from national and local retailers, including everyday savings, and local and national discounts and limited time offers.

Copyright © 2012 ADP, Inc. ADP and the ADP logo are registered trademarks of ADP, Inc. In the business of your success is a registered service mark of ADP, Inc. LifeCare,® Inc. All rights reserved.

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Frequently Asked Questions Q Who am I speaking to when I call LifeCare?

A LifeCare employs Bachelor’s and Master’s level specialists and licensed Master’s level clinicians.

Each specialist is educated and trained in one specialty area (child care, elder care, academics, etc.) so you receive guidance from experts in their fields.

Our clinicians provide a range of confidential professional services to help resolve problems that can affect your personal and work life; there is no question or issue too small.

Q How often can I use LifeCare services?

EAP you will have access to licensed, clinical staff for 3 sessions per year per issue; there is no limit on the number of issues that A For can be addressed per year.

For your other life events such as child care options, educational resources, caregiving questions, and home improvement services you have unlimited access to a LifeCare specialist and to the LifeMart online marketplace.

Q Are LifeCare services confidential?

LifeCare services are completely confidential. This means when you or a family member call the toll free number, neither your A Yes, employer nor anyone else will know you have used the services unless you choose to tell them.

Q Can my family members use these LifeCare services too? your family members are eligible to take advantage of LifeCare services. You can invite family members to use the LifeCare A Yes, services and register for the website on line by visiting your employer’s web portal or by calling 800-697-7315 and asking your specialist about registering your family members to use LifeCare services.

In addition, your household members and children up to the age of 26 are eligible for EAP services and have access to licensed, clinical staff for 3 sessions per year per issue; there is no limit on the number of issues that can be addressed per year.

Q Are LifeCare services available on the web? the LifeCare web site offers rich content, extensive search features, and a variety of interactive tools including LifeMart, an online A Yes, Discount Center. Highlights include; • Online provider searches and referrals: instantly access information on providers and resources (child care, adult care, schools, fitness centers, etc.) nationwide or request personalized referrals from a specialist via our interactive forms • Best-in-class content; read or download our extensive library of materials available in printable html, PDF, and hard copy, including: Parenting information from experts; Extensive content for seniors and caregivers; Health content including an A-Z index of health articles and consumer articles on everyday issues such as choosing cleaning services, personal safety and home improvement • Interactive tools and features Interactive quizzes on topics such as anger, anxiety, depression, lifestyle, patience, self-esteem and live virtual seminars and audio tips

Copyright © 2012 ADP, Inc. ADP and the ADP logo are registered trademarks of ADP, Inc. In the business of your success is a registered service mark of ADP, Inc. LifeCare,® Inc. All rights reserved.

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Annual Notices

Required Annual Employee Notices This document contains required notices as you are eligible for or enrolled in certain health and welfare plans. It contains the following: • • • •

Newborn’s Act Disclosure Women’s Health and Cancer Rights Act of 1998 (WHCRA) Michelle’s Law Premium assistance under Medicaid and Children’s Health Insurance Program HIPAA Notices Notice of Availability for HIPAA/Notice of Privacy Practices Notice of COBRA Continuation Coverage Rights Notice of Creditable Coverage Under Medicare Part D Notice of Non-Creditable Coverage Under Medicare Part D

Unless stated, if you have questions or concerns about any of these documents you can contact your plan administrator.

Name of Entity/Sender Contact-Position/Office Address Phone Number

BRG Management, Inc DBA Aspen Heights Human Resources Department 1301 S. Capital of Texas Hwy, B201, Austin, TX 78746 512-369-3030

We advise that you maintain a copy of these notices in a place where you can find them. They contain information regarding your health plans and other government programs that may impact the availability and cost of health care both now as an employee and in the future.

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden varies based on the information collected. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number.

May, 2014 ASPEN 2018 BENEFITS :: 130

Annual Notices Newborn’s 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).

Women’s Health and Cancer Rights Act of 1998 (WHCRA) - Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema?

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.

Michelle’s Law - Michelle’s Law, passed in 2008, prohibits group health plans from terminating coverage for a dependent child who has lost student status as a result of a medically necessary leave of absence. Plans must continue to provide coverage for up to one year or until coverage would otherwise terminate under the plan. Plans are allowed to require physician certification of the medical necessity for the leave of absence.

If you would like more information, please contact your plan administrator.

Name of Entity/Sender Contact-Position/Office Address Phone Number

BRG Management, Inc DBA Aspen Heights Human Resources Department 1301 S. Capital of Texas Hwy, B201, Austin, TX 78746 512-369-3030

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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.

This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of August 10, 2017. Contact your State for more information on eligibility –

ALABAMA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.asp x

ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

FLORIDA – Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

GEORGIA – Medicaid Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

IOWA – Medicaid Website: http://dhs.iowa.gov/ime/members/medicaid-a-toz/hipp Phone: 1-888-346-9562

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KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

KENTUCKY – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

LOUISIANA – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/masshe alth/ Phone: 1-800-862-4840

MINNESOTA – Medicaid Website: http://mn.gov/dhs/people-weserve/seniors/health-care/health-careprograms/programs-and-services/medicalassistance.jsp Phone: 1-800-657-3739

MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp. htm Phone: 573-751-2005

MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HI PP Phone: 1-800-694-3084

NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

NEVADA – Medicaid Medicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE – Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

NEW YORK – Medicaid Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

NORTH CAROLINA – Medicaid Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid / Phone: 1-844-854-4825

OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

PENNSYLVANIA – Medicaid Website: http://www.dhs.pa.gov/provider/medicalassistance/he althinsurancepremiumpaymenthippprogram/index.ht m Phone: 1-800-692-7462

RHODE ISLAND – Medicaid Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820 ASPEN 2018 BENEFITS :: 133

SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

TEXAS – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

UTAH – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

WASHINGTON – Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/program-administration/premium-paymentprogram Phone: 1-800-562-3022 ext. 15473

WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.p df Phone: 1-800-362-3002

WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance. cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since August 10, 2017, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.

The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)

ASPEN 2018 BENEFITS :: 134

HIPAA Notices Special Enrollment - 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 and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after you or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

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 enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Your group health plan will allow an employee or dependent who is eligible, but not enrolled, for coverage to enroll for coverage if either of the following events occurs: 1. TERMINATION OF MEDICAID OR CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) COVERAGE – If the employee or dependent is covered under a Medicaid plan or under a State child health plan and coverage of the employee or dependent under such a plan is terminated as a result of loss of eligibility.

2. ELIGIBILITY FOR EMPLOYMENT ASSISTANCE UNDER MEDICAID OR CHIP – If the employee or dependent becomes eligible for premium assistance under Medicaid or a State child health plan, including under any waiver or demonstration project conducted under or in relation to such a plan. This is usually a program where the state assists employed individuals with premium payment assistance for their employer’s group health plan rather than direct enrollment in a state Medicaid program.

To be eligible for this special enrollment opportunity you must request coverage under the group health plan within 60 days after the date the employee or dependent becomes eligible for premium assistance under Medicaid or CHIP or the date your or your dependent’s Medicaid or state-sponsored CHIP coverage ends.

Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on anything related to your health. In addition, a group health plan may not charge you (or your dependents) more for coverage, based on health, than the amount charged a similarly situated individual.

The Genetic Information Nondiscrimination Act (GINA). The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits discrimination in group health plan coverage based on genetic information. It expands the genetic information protections included in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and prevents a plan or issuer from imposing a pre-existing condition exclusion provision based solely on genetic information, and prohibits discrimination in individual eligibility, benefits, or premiums based on any health factor (including genetic information). GINA also generally prohibits plans and issuers from requesting or requiring an individual to undergo a genetic test and from collecting genetic information (including family medical history) prior to or in connection with enrollment, or for underwriting purposes.

May, 2014 ASPEN 2018 BENEFITS :: 135

HIPAA Notices Right to individual health coverage. Under HIPAA, if you are an “eligible individual”, you have a right to buy certain individual health policies (or in some states, to buy coverage through a high-risk pool) without a pre-existing condition exclusion. To be an eligible individual, you must meet the following requirements: You have had coverage for at least 18 months without a break in coverage of 63 days or more; Your most recent coverage was under a group health plan; Your group coverage was not terminated because of fraud or nonpayment of premiums; You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or continuation coverage under a similar state provision); and You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other health insurance coverage. The right to buy individual coverage is the same whether you are laid off, fired, or quit your job.

Therefore, if you are interested in obtaining individual coverage and you meet the other criteria to be an eligible individual, you should apply for this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break.

Special information for people on FMLA leave. If you are taking leave under the Family and Medical Leave Act (FMLA) and you drop health coverage during your leave, any days without health coverage while on FMLA leave will not count toward a 63-day break in coverage. In addition, if you do not return from leave, the 30-day period to request special enrollment in another plan will not start before your FMLA leave ends.

Therefore, when you apply for other health coverage, you should tell your plan administrator or health insurer about any prior FMLA leave.

Notice of Availability for HIPAA/Notice of Privacy Practices. Aspen Heights Welfare Benefits Plan would like to communicate the availability of its Notice of Privacy Practices. At any time, a copy of the current Notice of Privacy Practices may be obtained by accessing your ADP member portal or by contacting Human Resources at 512-910-3266.

For more information. If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor, Employee Benefits Security Administration (EBSA), toll-free at (866) 444-3272 (for free HIPAA publications ask for publications concerning changes in health care laws). You may also contact the CMS publication hotline at (800) 633-4227 (ask for Protecting Your Health Insurance Coverage). These publications and other useful information are also available on the Internet at: http://www.dol.gov/ebsa, the DOL’s interactive Web pages - Health Elaws, or http://www.cms.hhs.gov/healthinsreformforconsume/.

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Notice of COBRA Continuation Coverage Rights **Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you have recently gained coverage under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • •

Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • • •

The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the plan as a “dependent child.”

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

•

The end of employment or reduction of hours of employment; Death of the employee; The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both)

OMB Control Number 1210-0123 (expires 12/31/2019)

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Notice of COBRA Continuation Coverage Rights **Continuation Coverage Rights Under COBRA** For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 month of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA continuation coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.

Keep Your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members.

You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan contact information Name of Entity/Sender Name of Plan Contact-Position/Office

BRG Management, Inc DBA Aspen Heights Aspen Heights Welfare Benefits Plan Human Resources Department

OMB Control Number 1210-0123 (expires 12/31/2019)

May, 2014 ASPEN 2018 BENEFITS :: 138

Notice of COBRA Continuation Coverage Rights **Continuation Coverage Rights Under COBRA** Address Phone Number

1301 S. Capital of Texas Hwy, B201, Austin, TX 512-369-3030

OMB Control Number 1210-0123 (expires 12/31/2019)

May, 2014 ASPEN 2018 BENEFITS :: 139

Important Notice from BRG Management, Inc DBA Aspen Heights 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 BRG Management, Inc DBA Aspen Heights and about your options under Medicareâ&#x20AC;&#x2122;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 Medicareâ&#x20AC;&#x2122;s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. BRG Management, Inc DBA Aspen Heights has determined that the prescription drug coverage offered by the Aspen Heights Welfare Benefits Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) 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 15 th 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 BRG Management, Inc DBA Aspen Heights coverage will not be affected.

If you do decide to join a Medicare drug plan and drop your current BRG Management, Inc DBA Aspen Heights coverage, be aware that you and your dependents will be able to get this coverage back, subject to plan enrollment rules and Section 125 regulations.

OMB control number 0938-0990

May, 2014 ASPEN 2018 BENEFITS :: 140

Important Notice from BRG Management, Inc DBA Aspen Heights About Your Prescription Drug Coverage and Medicare 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 BRG Management, Inc DBA Aspen Heights 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’ll 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 BRG Management, Inc DBA Aspen Heights changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

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 (800) MEDICARE/(800) 633-4227); TTY users should call (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 at www.socialsecurity.gov Call them at (800) 772-1213; TTY (800) 325-0778.

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).

Plan Administrator contact information Date Name of Entity/Sender Contact--Position/Office Address Phone Number

OMB control number 0938-0990

10/9/17 BRG Management, Inc DBA Aspen Heights Human Resources Department 1301 S. Capital of Texas Hwy, B201, Austin, TX 512-369-3030

May, 2014 ASPEN 2018 BENEFITS :: 141

Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188

CERTIFICATE OF INSURANCE Metropolitan Life Insurance Company ("MetLife"), a stock company, certifies that You and Your Dependents are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY. This certificate is part of the Group Policy. The Group Policy is a contract between MetLife and the Employer and may be changed or ended without Your consent or notice to You. This certificate describes insurance provided by a certificate previously issued to You by MetLife and replaces such previous certificate.

Employer:

BRG Management Inc dba Aspen Heights

Group Policy Number:

KM 05932994-G

Type of Insurance:

Dental Insurance

MetLife Toll Free Number(s): For General Information

1-800-275-4638

THIS CERTIFICATE ONLY DESCRIBES DENTAL INSURANCE. FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED. THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE LAW OF A STATE OTHER THAN FLORIDA. THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS REQUIRED BY MARYLAND LAW. WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) CAREFULLY.

GCERT2000 fp

All Active Full-Time Employees who elect the Low Option Dental Plan RV 01/10/2017 1 ASPEN 2018 BENEFITS :: 142

IMPORTANT NOTICE

AVISO IMPORTANTE

To obtain information or make a complaint:

Para obtener información o para presentar una queja:

You may call MetLife’s toll free telephone number for information or to make a complaint at:

Usted puede llamar al número de teléfono gratuito de MetLife’s para obtener información o para presentar una queja al:

1-800-275-4638 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights, or complaints at:

1-800-252-3439

1-800-275-4638 Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre compañías, coberturas, derechos o quejas al:

1-800-252-3439

You may write the Texas Department of Insurance:

Usted puede escribir al Departamento de Seguros de Texas a:

P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007

P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007

Web: www.tdi.texas.gov

Sitio web: www.tdi.texas.gov

E-mail: ConsumerProtection@tdi.texas.gov

E-mail: ConsumerProtection@tdi.texas.gov

PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact MetLife first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

DISPUTAS POR PRIMAS DE SEGUROS O RECLAMACIONES: Si tiene una disputa relacionada con su prima de seguro o con una reclamación, usted debe comunicarse con MetLife primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas.

ATTACH THIS NOTICE TO YOUR CERTIFICATE: This notice is for information only and does not become a part or condition of the attached document.

ADJUNTE ESTE AVISO A SU CERTIFICADO: Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto.

GCERT2000 notice/tx 02/15

For Texas Residents 2 ASPEN 2018 BENEFITS :: 143

NOTICE FOR RESIDENTS OF ALASKA Reasonable and Customary Charges Reasonable and Customary Charges for Out-of-Network services will not be based less than an 80th percentile of the dental charges.

Reasonable Access to an In-Network Dentist If You do not have an In-Network Dentist within 50 miles of Your legal residence, We will reimburse You for the cost of Covered Services and materials provided by an Out-of-Network Dentist at the same benefit level as an In-Network Dentist.

Coordination of Benefits or Non-Duplication of Benefits with a Secondary Plan: If This Plan is Secondary, This Plan will determine benefits as if the services were obtained from This Plan’s In-Network provider under the following circumstances:   

the Primary Plan does not provide benefits through a provider network; both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains services through a provider in the Primary plan’s network who is not in This Plan’s network; or both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains services from a provider that is not part of the provider network of the Primary Plan or This Plan because no provider in the Primary Plan’s provider network or This Plan’s network is able to meet the particular health need of the covered person.

Procedures For Dental Claims Procedures for Presenting Claims for Dental Insurance Benefits All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Routine Questions on Dental Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1800-275-4638.

Claim Submission For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination After You submit a claim for Dental Insurance benefits to MetLife, MetLife will review Your claim and notify You of its decision to approve or deny Your claim.

Such notification will be provided to You within a 30 day period from the date You submitted Your claim; except for situations requiring an extension of time of up to 15 days because of matters beyond the control of MetLife. If MetLife needs such an extension, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason why the extension is needed, and state when it will make its determination. If an extension is needed because You did not provide sufficient information or filed an incomplete claim, the time from the date of MetLife’s notice requesting further information and an extension until MetLife receives the requested information does not count toward the time period MetLife is allowed to notify You as to its claim GCERT2000 notice/ak

3 ASPEN 2018 BENEFITS :: 144

NOTICE FOR RESIDENTS OF ALASKA decision. You will have 45 days to provide the requested information from the date You receive the notice requesting further information from MetLife.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Within 30 days after We receive Proof of Your claim, We will approve and pay the claim or We will deny the claim. If We deny the claim, We will provide You with the basis of Our denial or the specific additional information that We need to adjudicate Your claim. If We request additional information, We will approve and pay the claim or We will deny the claim within 15 days after We receive the additional information. If the claim is approved and not paid within the time period provided, the claim will accrue at an interest rate of 15 percent per year until the claim is paid.

Appealing the Initial Determination If MetLife denies Your claim, You may appeal the denial. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision, or as soon as reasonably possible for situations in which You cannot reasonably meet the deadline. Appeals must be in writing and must include at least the following information:     

Name of Employee Name of the Plan Reference to the initial decision Whether the appeal is the first or second appeal of the initial determination An explanation why You are appealing the initial determination.

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

After MetLife receives Your written request, MetLife will conduct a full and fair review of Your claim.

Deference will not be given to initial denials, and MetLife’s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. Your appeal will be reviewed by a person holding the same professional license as the treating Dental provider. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim.

MetLife will notify You in writing of its final decision within 18 days after MetLife’s receipt of Your written request for review.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

Second Level Appeal If You disagree with the response to the initial appeal of the denied claim, You have the right to a second level appeal. We shall communicate Our final determination to You within 18 calendar days from receipt of the GCERT2000 notice/ak

4 ASPEN 2018 BENEFITS :: 145

NOTICE FOR RESIDENTS OF ALASKA request, or as required by any applicable state or federal laws or regulations. Our communication to the You shall include the specific reasons for the determination.

External Appeal If You disagree with the response to the second appeal of the denied claim, You have the right to an external appeal. We will communicate the decision of the external appear agency in Writing. The decision will be made in accordance with the medical exigencies of the case involved, but in no event later than 21 working days after the appeal is filed, or, in the case of an expedited appeal, 72 hours after the time of requesting an external appeal of the health care insurer’s decision. Decisions made by an external appeal agency are binding on Us and You unless the aggrieved party files suit in superior court within 6 months from the decision of the external appeal agency. All costs of the external appeal process, except those incurred by You or the treating professional in support of the appeal, will be paid by Us.

Overpayments Recovery of Overpayments We have the right to recover any amount that is determined to be an overpayment, within 180 days from the date of service, whether for services received by You or Your Dependents.

An overpayment occurs if it is determined that: 

the total amount paid by Us on a claim for Dental Insurance benefits is more than the total of the benefits due to You under this certificate; or



payment We made should have been made by another group plan.

If such overpayment occurs, You have an obligation to reimburse Us. How We Recover Overpayments We may recover the overpayment, within 180 days from the date of service, from You by:   

stopping or reducing any future benefits payable for Dental Insurance; demanding an immediate refund of the overpayment from You; and taking legal action.

If the overpayment results from Our having made a payment to You that should have been made under another group plan, We may recover such overpayment within 180 days from the date of service, from one or more of the following:   

any other insurance company; any other organization; or any person to or for whom payment was made.

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5 ASPEN 2018 BENEFITS :: 146

NOTICE FOR RESIDENTS OF ARKANSAS If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact: Arkansas Insurance Department Consumer Services Division 1200 West Third Street Little Rock, Arkansas 72201 (501) 371-2640 or (800) 852-5494

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6 ASPEN 2018 BENEFITS :: 147

NOTICE FOR RESIDENTS OF CALIFORNIA IMPORTANT NOTICE TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE POLICYHOLDER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS YOU RECEIVE AFTER FILING A CLAIM. IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA INSURANCE DEPARTMENT AT: DEPARTMENT OF INSURANCE 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 1 (800) 927-4357

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7 ASPEN 2018 BENEFITS :: 148

NOTICE FOR RESIDENTS OF THE STATE OF CALIFORNIA California law provides that for dental insurance, domestic partners of California’s residents must be treated the same as spouses. If the certificate does not already have a definition of domestic partner, then the following definition applies: “Domestic Partner means each of two people, one of whom is an employee of the Employer, a resident of California and who have registered as domestic partners or members of a civil union with the California or another government recognized by California as having similar requirements.

For purposes of determining who may become a Covered Person, the term does not include any person who:  

is in the military of any country or subdivision of a country; is insured under the Group Policy as an employee.”

If the certificate already has a definition of domestic partner, that definition will apply to California residents, as long as it recognizes as a domestic partner any person registered as the employee’s domestic partner with the California government or another government recognized by California as having similar requirements.

Wherever the term Spouse appears, except in the definition of Spouse, it shall be replaced by Spouse or Domestic Partner.

Wherever the term step-child appears, it is replaced by step-child or child of Your Domestic Partner.

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8 ASPEN 2018 BENEFITS :: 149

NOTICE FOR RESIDENTS OF GEORGIA IMPORTANT NOTICE The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence.

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9 ASPEN 2018 BENEFITS :: 150

NOTICE FOR RESIDENTS OF IDAHO If You have a question concerning Your coverage or a claim, first contact the Employer. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Employer and MetLife, You should feel free to contact: Idaho Department of Insurance Consumer Affairs 700 West State Street, 3rd Floor PO Box 83720 Boise, Idaho 83720-0043 1-800-721-3272 or www.DOI.Idaho.gov

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10 ASPEN 2018 BENEFITS :: 151

NOTICE FOR RESIDENTS OF ILLINOIS IMPORTANT NOTICE To make a complaint to MetLife, You may write to: MetLife 200 Park Avenue New York, New York 10166 The address of the Illinois Department of Insurance is: Illinois Department of Insurance Public Services Division Springfield, Illinois 62767

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11 ASPEN 2018 BENEFITS :: 152

NOTICE FOR RESIDENTS OF INDIANA Questions regarding your policy or coverage should be directed to: Metropolitan Life Insurance Company 1-800-275-4638 If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204 Consumer Hotline: (800) 622-4461; (317) 232-2395 Complaint can be filed electronically at www.in.gov/idoi

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12 ASPEN 2018 BENEFITS :: 153

NOTICE FOR RESIDENTS OF MAINE You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a default on Your part, such as nonpayment of a contribution that is due. The intent is to allow reinstatements where the default is due to the insured personâ&#x20AC;&#x2122;s suffering from cognitive impairment or functional incapacity.

You may make this designation by completing a "Third-Party Notice Request Form" and sending it to MetLife.

Once You have made a designation, You may cancel or change it by filling out a new Third-Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date MetLife receives the form. Call MetLife at the toll-free telephone number shown on the face page of this certificate to obtain a Third-Party Notice Request Form. Within 90 days after cancellation of coverage for nonpayment of premium, You, any person authorized to act on Your behalf, or any covered Dependent may request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional incapacity at the time of cancellation.

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13 ASPEN 2018 BENEFITS :: 154

NOTICE FOR MASSACHUSETTS RESIDENTS The following provisions are required by Massachusetts law.

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14

ASPEN 2018 BENEFITS :: 155

NOTICE FOR MASSACHUSETTS RESIDENTS (Continued) The following provisions are required by Massachusetts law.

Summary of Utilization Review Procedures MetLife reviews claims for evidence of need for certain dental procedures. These reviews are conducted by licensed dentists. If there is no evidence of need MetLife will deny benefits for a claim. MetLife also reviews claims to determine whether there exists a less costly treatment for a dental condition that is generally considered effective to treat the condition. If a less costly alternative treatment exists, MetLife will determine benefits based on the alternative treatment. If you want to determine the status of any such claim review, you can call MetLife at 1-800-275-4638.

Summary of Quality Assurance Programs MetLife performs a check on certain credentials of any dentist applying to participate in MetLifeâ&#x20AC;&#x2122;s Participating Dentist Program (PDP). If the credentials do not meet MetLifeâ&#x20AC;&#x2122;s standards, for example if a dentist does not have a valid license, the dentist will not be permitted to participate in the PDP. MetLife does not interfere with the traditional relationship between PDP dentists and their patients, or any determination between the patient and dentist as to what the appropriate dental treatment may be. MetLife dental plans also allow you to choose between any dentist, whether they participate in the PDP or not. Therefore you should choose your dentist carefully, and you are responsible to be sure that your dentist delivers quality dental care.

Involuntary Disenrollment Rate The involuntary disenrollment rate among insureds of MetLife is 0.

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15 2018 BENEFITS :: 156 ASPEN

NOTICE FOR RESIDENTS OF MASSACHUSETTS CONTINUATION OF DENTAL INSURANCE 1. If Your Dental Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be continued for 90 days after the date it ends.

2. If Your Dental Insurance ends because:  

You cease to be in an Eligible Class; or Your employment terminates;

for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days after the date it ends.

Continuation of Your Dental Insurance under the CONTINUATION WITH PREMIUM PAYMENT subsection will end before the end of continuation periods shown above if You become covered for similar benefits under another plan.

Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws, Chapter 151A, Section 71A. CONTINUATION OF DENTAL INSURANCE FOR YOUR FORMER SPOUSE If the judgment of divorce dissolving Your marriage provides for continuation of insurance for Your former Spouse when You remarry, Dental Insurance for Your former Spouse that would otherwise end may be continued.

To continue Dental insurance under this provision: 1. You must make a written request to the employer to continue such insurance; 2. You must make any required premium to the employer for the cost of such insurance.

The request form will be furnished by the Employer.

Such insurance may be continued from the date Your marriage is dissolved until the earliest of the following: 

the date Your former Spouse remarries;



the date of expiration of the period of time specified in the divorce judgment during which You are required to provide Dental Insurance for Your former Spouse;



the date coverage is provided under any other group health plan;



the date Your former Spouse becomes entitled to Medicare;



the date Dental Insurance under the policy ends for all active employees, or for the class of active employees to which You belonged before Your employment terminated;



the date of expiration of the last period for which the required premium payment was made; or



the date such insurance would otherwise terminate under the policy.

If Your former Spouse is eligible to continue Dental Insurance under this provision and any other provision of this Policy, all such continuation periods will be deemed to run concurrently with each other and shall not be deemed to run consecutively.

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16 ASPEN 2018 BENEFITS :: 157

NOTICE FOR NEW HAMPSHIRE RESIDENTS CONTINUATION OF YOUR DENTAL INSURANCE If You are a resident of New Hampshire, Your Dental Insurance may be continued if it ends because Your employment ends unless: 

Your employment ends due to Your gross misconduct;



this Dental Insurance ends for all employees;



this Dental Insurance is changed to end Dental Insurance for the class of employees to which You belong;



You are entitled to enroll in Medicare; or



Your Dental Insurance ends because You failed to pay the required premium.

The Employer must give You written notice of: 

Your right to continue Your Dental Insurance;



the amount of premium payment that is required to continue Your Dental Insurance;



the manner in which You must request to continue Your Dental Insurance and pay premiums; and



the date by which premium payments will be due.

The premium that You must pay for Your continued Dental Insurance may include: 

any amount that You contributed for Your Dental Insurance before it ended;



any amount the Employer paid; and



an administrative charge which will not to exceed two percent of the rest of the premium.

To continue Your Dental Insurance, You must: 

send a written request to continue Your Dental Insurance; and



pay the first premium within 30 days after the date Your employment ends.

The maximum continuation period will be the longest of: 

36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;



29 months if You become entitled to disability benefits under Social Security within 60 days of the date Your Employment ends; or 18 months.



Your continued Dental Insurance will end on the earliest of the following to occur: 

the end of the maximum continuation period;



the date this Dental Insurance ends;



the date this Dental Insurance is changed to end Dental Insurance for the class of employees to which You belong;



the date You are entitled to enroll for Medicare;



if You do not pay the required premium to continue Your Dental Insurance; or



the date You become eligible for coverage under any other group dental coverage.

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17 ASPEN 2018 BENEFITS :: 158

NOTICE FOR NEW HAMPSHIRE RESIDENTS (Continued) CONTINUATION OF YOUR DEPENDENT’S DENTAL INSURANCE If You are a resident of New Hampshire, Your Dental Insurance for Your Dependents may be continued if it ends because Your employment ends, Your marriage ends in divorce or separation, or You die, unless: 

Your employment ends due to Your gross misconduct;



this Dental Insurance ends for all Dependents;



this Dental Insurance is changed, for the class of employees to which You belong, to end Dental Insurance for Dependents;



the Dependent is entitled to enroll in Medicare; or



Your Dental Insurance for Your Dependents ends because You fail to pay a required premium.

If Dental Insurance for Your Dependents ends because Your marriage ends in divorce or separation, the party responsible under the divorce decree or separation agreement for payment of premium for continued Dental Insurance must notify the employer, in writing, within 30 days of the date of the divorce decree or separation agreement that the divorce or separation has occurred. If You and Your divorced or separated Spouse share responsibility for payment of the premium for continued Dental Insurance, both You and Your divorced or separated Spouse must provide the notification.

The Employer must give You, or Your former Spouse if You have died or Your marriage has ended, written notice of: 

Your right to continue Your Dental Insurance for Your Dependents;



the amount of premium payment that is required to continue Your Dental Insurance for Your Dependents;



the manner in which You or Your former Spouse must request to continue Your Dental Insurance for Your Dependents and pay premiums; and



the date by which premium payments will be due.

The premium that You or Your former Spouse must pay for continued Dental Insurance for Your Dependents may include: 

any amount that You contributed for Your Dental Insurance before it ended; and



any amount the Employer paid.

To continue Dental Insurance for Your Dependents, You or Your former Spouse must: 

send a written request to continue Dental Insurance for Your Dependents; and



must pay the first premium within 30 days of the date Dental Insurance for Your Dependents ends.

If You, and Your former Spouse, if applicable, fail to provide any required notification, or fail to request to continue Dental Insurance for Your Dependents and pay the first premium within the time limits stated in this section, Your right to continue Dental Insurance for Your Dependents will end.

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18 ASPEN 2018 BENEFITS :: 159

NOTICE FOR NEW HAMPSHIRE RESIDENTS (Continued) CONTINUATION OF YOUR DEPENDENT’S DENTAL INSURANCE (Continued) The maximum continuation period will be the longest of the following that applies: 

36 months if Dental Insurance for Your Dependents ends because Your marriage ends in divorce or separation, except that with respect to a Spouse who is age 55 or older when your marriage ends in divorce or separation the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group plan;



36 months if Dental Insurance for Your Dependents ends because You die, except that with respect to a Spouse who is age 55 or older when You die, the maximum continuation period will end when Your surviving Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;



36 months if Dental Insurance for Your Dependents ends because You become entitled to benefits under Title XVIII of Social Security, except that with respect to a Spouse who is age 55 or older when You become entitled to benefits under Title XVIII of Social Security, the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;



36 months if You become entitled to benefits under Title XVIII of Social Security while You are already receiving continued benefits under this section, except that with respect to a Spouse who is age 55 or older when You first become entitled to continue Your Dental Insurance the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;



36 months with respect to a Dependent Child if Dental Insurance ends because the Child ceases to be a Dependent Child;



36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;



29 months if Dental Insurance for Your Dependents ends because Your employment ends, and within 60 days of the date Your employment ends you become entitled to disability benefits under Social Security; or



18 months if Dental Insurance for Your Dependents ends because Your employment ends.

A Dependent's continued Dental Insurance will end on the earliest of the following to occur: 

the end of the maximum continuation period;



the date this Dental Insurance ends;



the date this Dental Insurance is changed to end Dental Insurance for Dependents for the class of employees to which You belong;



the date the Dependent becomes entitled to enroll for Medicare;



if You do not pay a required premium to continue Dental Insurance for Your Dependents; or



the date the Dependent becomes eligible for coverage under any other group dental coverage.

GCERT2000 notice/coi/nh

19 ASPEN 2018 BENEFITS :: 160

NOTICE FOR RESIDENTS OF NORTH CAROLINA UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER, PRINCIPAL, AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE PAYMENT OF GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS, SHALL: (1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE INSURANCE, HOSPITAL, MEDICAL, OR DENTAL SERVICE CORPORATION PLAN, MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN COVERAGES AND THE CONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSONS INSURED, BY WILLFULLY FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE WITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT, AND (2) WILLFULLY FAIL TO DELIVER, AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE COVERAGES, TO ALL PERSONS COVERED BY THE GROUP POLICY A WRITTEN NOTICE OF THE PERSON'S INTENTION TO STOP PAYMENT OF PREMIUMS. THIS WRITTEN NOTICE MUST ALSO CONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP POLICY OF THEIR RIGHTS TO HEALTH INSURANCE CONVERSION POLICIES UNDER ARTICLE 53 OF CHAPTER 58 OF THE GENERAL STATUTES AND THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THE FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE 68 OF CHAPTER 58 OF THE GENERAL STATUTES. VIOLATION OF THIS LAW IS A FELONY. ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECT TO A COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOR EXPENSES OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE.

GCERT2000 notice/nc

20 ASPEN 2018 BENEFITS :: 161

NOTICE FOR RESIDENTS OF PENNSYLVANIA Dental Insurance for a Dependent Child may be continued past the age limit if that Child is a fulltime student and insurance ends due to the Child being ordered to active duty (other than active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the United States.

Insurance will continue if such Child:    

re-enrolls as a full-time student at an accredited school, college or university that is licensed in the jurisdiction where it is located; re-enrolls for the first term or semester, beginning 60 or more days from the child’s release from active duty; continues to qualify as a Child, except for the age limit; and submits the required Proof of the child’s active duty in the National Guard or a Reserve Component of the United States Armed Forces.

Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of the date:  

the insurance has been continued for a period of time equal to the duration of the child’s service on active duty; or the child is no longer a full-time student.

GCERT2000 notice/pa

21 ASPEN 2018 BENEFITS :: 162

NOTICE FOR RESIDENTS OF ALL STATES THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.

GCERT2000 notice/tx/wc

22 ASPEN 2018 BENEFITS :: 163

NOTICE FOR RESIDENTS OF UTAH Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Utah law, which determines who and what is covered and the amounts of coverage.

The Association was established to provide protection in the unlikely event that your life, health, or annuity insurance company becomes financially unable to meet its obligations and is taken over by its insurance regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other insurance companies.

The basic protections provided by the Association are:  Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values  Health Insurance o $500,000 in hospital, medical and surgical insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in disability income insurance benefits o $500,000 in other types of health insurance benefits  Annuities o $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits.

Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a complete description of coverage, consult Utah Code, Title 3 lA, Chapter 28.

Insurance companies and agents are prohibited by Utah law to use the existence of the Association or its coverage to encourage you to purchase insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between Utah law and this notice, Utah law will control.

To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.utlifega.org or contact: Utah Life and Health Insurance Guaranty Assoc.

60 East South Temple, Suite 500 Salt Lake City UT 84111 (801) 320-9955

Utah Insurance Department 3110 State Office Building Salt Lake City UT 84114-6901 (801) 538-3800

A written complaint about misuse of this Notice or the improper use of the existence of the Association may be filed with the Utah Insurance Department at the above address.

GTY-NOTICE-UT-0710

23 ASPEN 2018 BENEFITS :: 164

NOTICE FOR RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have additional questions You may contact the insurance company issuing this insurance at the following address and telephone number: MetLife 200 Park Avenue New York, New York 10166 Attn: Corporate Consumer Relations Department To phone in a claim related question, You may call Claims Customer Service at: 1-800-275-4638 If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the Virginia State Corporation Commissionâ&#x20AC;&#x2122;s Bureau of Insurance at: The Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA 23209 1-877-310-6560 - toll-free 1-804-371-9032 - locally www.scc.virginia.gov - web address ombudsman@scc.virginia.gov - email Or: The Virginia Department of Health (The Center for Quality Health Care Services and Consumer Protection) 3600 West Broad St Suite 216 Richmond, VA 23230 1-800-955-1819 Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your agent, company or the Bureau of Insurance, have Your policy number available.

GCERT2000 notice/va

24 ASPEN 2018 BENEFITS :: 165

NOTICE FOR RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE If You have any questions regarding an appeal or grievance concerning the dental services that You have been provided that have not been satisfactorily addressed by this Dental Insurance, You may contact the Virginia Office of the Managed Care Ombudsman for assistance.

You may contact the Virginia Office of the Managed Care Ombudsman either by dialing toll free at (877) 3106560, or locally at (804) 371-9032, via the internet at Web address www.scc.virginia.gov, email at ombudsman@scc.virginia.gov, or mail to: The Office of the Managed Care Ombudsman Bureau of Insurance, P.O. Box 1157 Richmond, VA 23218

GCERT2000 notice/va1

25 ASPEN 2018 BENEFITS :: 166

NOTICE FOR RESIDENTS OF WISCONSIN

KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? - If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.

MetLife Attn: Corporate Consumer Relations Department 200 Park Avenue New York, NY 10166-0188 1-800-638-5433

You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsinâ&#x20AC;&#x2122;s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting:

Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1-800-236-8517 outside of Madison or 608-266-0103 in Madison.

GCERT2000 notice/wi

26 ASPEN 2018 BENEFITS :: 167

NOTICE FOR RESIDENTS OF LOUISIANA, MINNESOTA, MONTANA, NEW MEXICO, UTAH AND WASHINGTON The Definition of Child In The Definitions Section Of This Certificate Is Modified For The Coverage Listed Below: For Louisiana Residents (Dental Insurance): The term also includes Your grandchildren residing with You. The age limit for children and grandchildren will not be less than 26, regardless of the child’s or grandchild’s marital status, student status or full-time employment status. Your natural child, adopted child, stepchild or grandchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. In addition, marital status will not prevent or cease the continuation of insurance for a mentally or physically handicapped child or grandchild past the age limit.

For Minnesota Residents (Dental Insurance): The term also includes Your grandchildren who are financially dependent upon You and reside with You continuously from birth. The age limit for children and grandchildren will not be less than 25 regardless of the child’s or grandchild’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a Child under this insurance.

For Montana Residents (Dental Insurance): The term also includes newborn infants of any person insured under this certificate. The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a child under this insurance.

For New Mexico Residents (Dental Insurance): The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild will not be denied dental insurance coverage under this certificate because:   

that child was born out of wedlock; that child is not claimed as Your dependent on Your federal income tax return; or that child does not reside with You.

For Utah Residents (Dental Insurance): The age limit for children will not be less than 26, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported

by You to qualify as a Child under this insurance.

For Washington Residents Dental Insurance: The age limit for children will not be less than 26, regardless of the child’s marital status, student status, or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance.

GCERT2000 notice/childdef

27 ASPEN 2018 BENEFITS :: 168

NOTICE FOR RESIDENTS OF ALL STATES WHO ARE INSURED FOR DENTAL INSURANCE Notice Regarding Your Rights and Responsibilities Rights: 

We will treat communications, financial records and records pertaining to your care in accordance with all applicable laws relating to privacy.



Decisions with respect to dental treatment are the responsibility of You and the dentist. We neither require nor prohibit any specified treatment. However, only certain specified services are covered for benefits. Please see the Dental Insurance sections of this certificate for more details.



You may request a pre-treatment estimate of benefits for the dental services to be provided. However, actual benefits will be determined after treatment has been performed.



You may request a written response from MetLife to any written concern or complaint.



You have the right to receive an explanation of benefits which describes the benefit determinations for your dental insurance.

Responsibilities: 

You are responsible for the prompt payment of any charges for services performed by the dentist. If the dentist agrees to accept part of the payment directly from MetLife, you are responsible for prompt payment of the remaining part of the dentist’s charge.



You should consult with the dentist about treatment options, proposed and potential procedures, anticipated outcomes, potential risks, anticipated benefits and alternatives. You should share with the dentist the most current, complete and accurate information about your medical and dental history and current conditions and medications.



You should follow the treatment plans and health care recommendations agreed upon by You and the dentist.

GCERT2000 notice/denrights

28 ASPEN 2018 BENEFITS :: 169

TABLE OF CONTENTS The bottom left of each page of this certificate has a unique coding which describes the section of the certificate that the page contains (fp = Certificate Face Page, sch = Schedule of Benefits).

Section Page CERTIFICATE FACE PAGE ............................................................................................................................... 1 NOTICES ............................................................................................................................................................ 2 TABLE OF CONTENTS .................................................................................................................................... 29 SCHEDULE OF BENEFITS .............................................................................................................................. 30 DEFINITIONS ................................................................................................................................................... 31 ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ...................................................................................... 34 Eligible Classes ............................................................................................................................................. 34 Date You Are Eligible For Insurance ............................................................................................................. 34 Enrollment Process For Dental Insurance..................................................................................................... 34 Date Your Insurance Takes Effect ................................................................................................................ 34 Date Your Insurance Ends ............................................................................................................................ 35 ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS ......................................................... 36 Eligible Classes For Dependent Insurance ................................................................................................... 36 Date You Are Eligible For Dependent Insurance .......................................................................................... 36 Enrollment Process For Dependent Dental Insurance .................................................................................. 36 Date Your Insurance Takes Effect For Your Dependents................................................................................ 36 Date Your Insurance For Your Dependents Ends ......................................................................................... 37 DENTAL INSURANCE: SPECIAL RULES FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP DENTAL COVERAGE ........................................................................................................................ 39 CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.................................................................... 40 For Mentally or Physically Handicapped Children ......................................................................................... 40 For Family And Medical Leave ...................................................................................................................... 40 COBRA Continuation For Dental Insurance .................................................................................................. 40 At The Employer's Option.............................................................................................................................. 40 EVIDENCE OF INSURABILITY ........................................................................................................................ 42 DENTAL INSURANCE ...................................................................................................................................... 43 DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES ............................................................... 46 Type A Covered Services .............................................................................................................................. 46 Type B Covered Services .............................................................................................................................. 46 Type C Covered Services.............................................................................................................................. 48 Type D Covered Services.............................................................................................................................. 49 DENTAL INSURANCE: EXCLUSIONS ............................................................................................................ 50 DENTAL INSURANCE: COORDINATION OF BENEFITS ............................................................................... 52 FILING A CLAIM ............................................................................................................................................... 57 DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS .................................................................... 58 GENERAL PROVISIONS.................................................................................................................................. 60 Assignment .................................................................................................................................................... 60 Dental Insurance: Who We Will Pay ............................................................................................................. 60 Entire Contract............................................................................................................................................... 60 Incontestability: Statements Made By You .................................................................................................... 60 Misstatement of Age ...................................................................................................................................... 60 Conformity With Law ..................................................................................................................................... 60 Autopsy .......................................................................................................................................................... 60 Overpayments ............................................................................................................................................... 60

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29 ASPEN 2018 BENEFITS :: 170

SCHEDULE OF BENEFITS This schedule shows the benefits that are available under the Group Policy. You and Your Dependents will only be insured for the benefits:   

for which You and Your Dependents become and remain eligible, and which You elect, if subject to election; and which are in effect.

BENEFIT

BENEFIT AMOUNT AND HIGHLIGHTS

Dental Insurance For You and Your Dependents For All Active Full-Time Employees who elect the Low Option Dental Plan

Covered Percentage for:

In-Network based on the Maximum Allowed Charge

Out-of-Network based on the Maximum Allowed Charge

Type A Services

100%

100%

Type B Services

100%

100%

Type C Services

60%

60%

Type D Services (Orthodontic)

50%

50%

Deductibles for:

In-Network

Out-of-Network

Yearly Individual Deductible

$50 for the following Covered Services Combined: Type B & Type C

$50 for the following Covered Services Combined: Type B & Type C

Yearly Family Deductible

$150 for the following Covered Services Combined: Type B & Type C

$150 for the following Covered Services Combined: Type B & Type C

Maximum Benefit:

In-Network

Out-of-Network

Yearly Individual Maximum

$1,750 for the following Covered Services: Type A, Type B & Type C $1,500

$1,750 for the following Covered Services: Type A, Type B & Type C $1,500

Lifetime Individual Maximum for Type D Covered Services (Orthodontic)

GCERT2000 sch

30 ASPEN 2018 BENEFITS :: 171

DEFINITIONS As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning.

Actively at Work or Active Work means that You are performing all of the usual and customary duties of Your job on a Full-Time basis. This must be done at:   

the Employer's place of business; an alternate place approved by the Employer; or a location to which the Employer's business requires You to travel.

You will be deemed to be Actively at Work during weekends or Employer-approved vacations, holidays or business closures if You were Actively at Work on the last scheduled work day preceding such time off.

Cast Restoration means an inlay, onlay, or crown.

Child means the following: (for residents of Louisiana, Minnesota, Montana, New Mexico, Utah and Washington, the Child Definition is modified as explained in the Notice pages of this certificate - please consult the Notice) For Dental Insurance, Your natural or adopted child; Your stepchild (including the child of a Domestic Partner); or a child who resides with and is fully supported by You; and who, in each case, is under age 26.

The term also includes Your grandchild who is under age 26, and who was able to be claimed by You as a Dependent for Federal Income Tax purposes at the time You applied for Dental Insurance.

A child will be considered Your adopted child during the period You are party to a suit in which You are seeking the adoption of the child.

If You provide Us notice, a Child also includes a child for whom You must provide Dental Insurance due to a Qualified Medical Child Support Order as defined in the United States Employee Retirement Income Security Act of 1974 as amended.

The term does not include any person who:  

is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or is insured under the Group Policy as an employee.

Contributory Insurance means insurance for which the Employer requires You to pay any part of the premium.

Contributory Insurance includes: Personal and Dependent Dental Insurance.

Covered Percentage means the percentage of the Maximum Allowed Charge that We will pay for a Covered Service performed by an In-Network Dentist or an Out-of-Network Dentist after any required Deductible is satisfied.

Covered Service means a dental service used to treat Your or Your Dependent’s dental condition which is:   

prescribed or performed by a Dentist while such person is insured for Dental Insurance; Dentally Necessary to treat the condition; and described in the SCHEDULE OF BENEFITS or DENTAL INSURANCE sections of this certificate.

Deductible means the amount You or Your Dependents must pay before We will pay for Covered Services.

GCERT2000 def

as amended by GCR09-07 dp/tx 31 ASPEN 2018 BENEFITS :: 172

DEFINITIONS Dental Hygienist means a person trained to:  

remove calcareous deposits and stains from the surfaces of teeth; and provide information on the prevention of oral disease.

Dentally Necessary means that a dental service or treatment is performed in accordance with generally accepted dental standards as determined by Us and is:  

necessary to treat decay, disease or injury of the teeth; or essential for the care of the teeth and supporting tissues of the teeth.

Dentist means:  

a person licensed to practice dentistry in the jurisdiction where such services are performed; or any other person whose services, according to applicable law, must be treated as Dentist’s services for purposes of the Group Policy. Each such person must be licensed in the jurisdiction where the services are performed and must act within the scope of that license. The person must also be certified and/or registered if required by such jurisdiction.

Dentures means fixed partial dentures (bridgework), removable partial dentures and removable full dentures.

Dependent(s) means Your Spouse and/or Child.

Domestic Partner means each of two people, one of whom is an employee of the Employer, who: 

have registered as each other's domestic partner, civil union partner or reciprocal beneficiary with a government agency where such registration is available; or



are of the same or opposite sex and have a mutually dependent relationship so that each has an insurable interest in the life of the other. Each person must be: 1.

2.

3.

4.

5.

18 years of age or older; unmarried; the sole domestic partner of the other; sharing a primary residence with the other; and not related to the other in a manner that would bar their marriage in the jurisdiction in which they reside.

A Domestic Partner declaration attesting to the existence of an insurable interest in one another's lives must be completed and Signed by the employee.

Full-Time means Active Work on the Employer's regular work schedule for the class of employees to which You belong. The work schedule must be at least 30 hours a week. Full-Time does not include temporary or seasonal employees.

In-Network Dentist means a Dentist who participates in the Preferred Dentist Program and has a contractual agreement with Us to accept the Maximum Allowed Charge as payment in full for a dental service.

Maximum Allowed Charge means the lesser of:  

the amount charged by the Dentist; or the maximum amount which the In-Network Dentist has agreed with Us to accept as payment in full for the dental service.

Noncontributory Insurance means insurance for which the Employer does not require You to pay any part of the premium.

GCERT2000 def

as amended by GCR09-07 dp/tx 32 ASPEN 2018 BENEFITS :: 173

DEFINITIONS Out-of-Network Dentist means a Dentist who does not participate in the Preferred Dentist Program.

Physician means:  

a person licensed to practice medicine in the jurisdiction where such services are performed; or any other person whose services, according to applicable law, must be treated as Physician’s services for purposes of the Group Policy. Each such person must be licensed in the jurisdiction where the service is performed and must act within the scope of that license. Such person must also be certified and/or registered if required by such jurisdiction.

Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish:   

the nature and extent of the loss or condition; Our obligation to pay the claim; and the claimant’s right to receive payment.

Proof must be provided at the claimant’s expense.

Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

Spouse means Your lawful Spouse. The term also includes Your Domestic Partner.

The term does not include any person who:  

is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or is insured under the Group Policy as an employee.

We, Us and Our mean MetLife.

Written or Writing means a record which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

Year or Yearly means the 12 month period that begins January 1.

You and Your mean an employee who is insured under the Group Policy for the insurance described in this certificate.

GCERT2000 def

as amended by GCR09-07 dp/tx 33 ASPEN 2018 BENEFITS :: 174

ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ELIGIBLE CLASS(ES) All Active Full-Time Employees who elect the Low Option Dental Plan

DATE YOU ARE ELIGIBLE FOR INSURANCE You may only become eligible for the insurance available for Your class as shown in the SCHEDULE OF BENEFITS. For All Active Full-Time Employees who elect the Low Option Dental Plan You will be eligible for insurance on the later of: 1. January 01, 2017; and 2. the first day of the month coincident with or next following the date You enter that class.

Waiting Period means the period of continuous membership in an eligible class that You must wait before You become eligible for insurance. This period begins on the date You enter an eligible class and ends on the date You complete the period(s) specified.

ENROLLMENT PROCESS FOR DENTAL INSURANCE If You are eligible for insurance, You may enroll for such insurance by completing the required form in Writing.

If You enroll for Contributory Insurance, You must also give the Employer Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Employer how much You will be required to contribute.

The Dental Insurance has a regular enrollment period established by the Employer. Subject to the rules of the Group Policy, You may enroll for Dental Insurance only when You are first eligible or during an annual enrollment period or If You have a Qualifying Event. You should contact the Employer for more information regarding the annual enrollment period.

DATE YOUR INSURANCE TAKES EFFECT Enrollment When First Eligible If You complete the enrollment process within 31 days of becoming eligible for insurance you are a timely entrant, such insurance will take effect on the date You become eligible, provided You are Actively at Work on that date.

If You are not Actively at Work on the date the insurance would otherwise take effect, the benefit will take effect on the day You resume Active Work.

Enrollment During First Annual Enrollment Period Following the Date You Became Eligible You will be able to enroll for insurance during the first annual enrollment period. When You complete the enrollment process during the first annual enrollment period, such insurance will take effect on the first day of the month coincident with or next following the enrollment period, if You are actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

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34 ASPEN 2018 BENEFITS :: 175

ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (CONTINUED) Enrollment During Any Subsequent Dental Enrollment Period During any subsequent annual enrollment period for dental insurance as determined by the Employer, You may enroll for insurance for which You are eligible or choose a different option than the one for which You are currently enrolled. If You are not currently enrolled for Dental Insurance but You enroll or make changes to Your insurance during a subsequent enrollment period, the Dental Insurance takes effect on the first day of the month following the enrollment period, if You are Actively at Work on that day.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment Due to a Qualifying Event You may enroll for insurance for which You are eligible or change the amount of Your insurance between annual enrollment periods only if You have a Qualifying Event.

If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or changes to Your insurance made as a result of a Qualifying Event will take effect on the date of the Qualifying Event, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Qualifying Event includes: 

marriage; or



the birth, adoption or placement for adoption of a dependent child; or



divorce, legal separation or annulment; or



the death of a dependent; or



You previously did not enroll for dental coverage for You or Your dependent because You had other group coverage, but that coverage has ceased due to loss of eligibility for the other group coverage; or



Your dependent's ceasing to qualify as a dependent under this insurance or under other group coverage.

DATE YOUR INSURANCE ENDS Your insurance will end on the earliest of: 1. the date the Group Policy ends; 2. the date insurance ends for Your class; 3. the end of the period for which the last premium has been paid for You; 4. the last day of the calendar month in which Your employment ends; Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; or 5. the last day of the calendar month in which You retire in accordance with the Employer’s retirement plan.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.

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35 ASPEN 2018 BENEFITS :: 176

ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS ELIGIBLE CLASS(ES) FOR DEPENDENT INSURANCE All Active Full-Time Employees who elect the Low Option Dental Plan

DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE You may only become eligible for the Dependent insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. For All Active Full-Time Employees who elect the Low Option Dental Plan

You will be eligible for Dependent insurance on the later of: 1. January 01, 2017; and 2. the first day of the month coincident with or next following the date You enter that class.

Waiting Period means the period of continuous membership in an eligible class that You must wait before You become eligible for Dependent insurance. This period begins on the date You enter an eligible class and ends on the date You complete the period(s) specified.

No person may be insured as a Dependent of more than one employee.

ENROLLMENT PROCESS FOR DEPENDENT DENTAL INSURANCE If You are eligible for Dependent Insurance, You may enroll for such insurance by completing the required form in Writing for each Dependent to be insured. If You enroll for Contributory Insurance, You must also give the Employer Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Employer how much You will be required to contribute.

In order to enroll for Dental Insurance for Your Dependents, You must either (a) already be enrolled for Dental Insurance for You or (b) enroll at the same time for Dental Insurance for You. The Dental Insurance has a regular enrollment period established by the Employer. Subject to the rules of the Group Policy, You may enroll for Dependent Dental Insurance only when You are first eligible or during an annual enrollment period or If You have a Qualifying Event. You should contact the Employer for more information regarding the annual enrollment period.

DATE YOUR INSURANCE TAKES EFFECT FOR YOUR DEPENDENTS Enrollment When First Eligible If You complete the enrollment process for Dependent Dental Insurance within 31 days of becoming eligible for Dependent Insurance you are a timely entrant, such insurance will take effect on the later of:  

the date You become eligible for such insurance; and the date You enroll

provided You are Actively at Work on that date. If You are not Actively at Work on that date, it will take effect on the day You return to Active Work.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (CONTINUED) Enrollment During First Annual Enrollment Period Following the Date You Became Eligible You will be able to enroll for Dependent Insurance during the first annual enrollment period. When You complete the enrollment process during the first annual enrollment period, such insurance will take effect on the first day of the month coincident with or next following the enrollment period, if You are actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment During Any Subsequent Dental Enrollment Period During any subsequent annual enrollment period for dental insurance as determined by the Employer, You may enroll for insurance for which You are eligible or choose a different option than the one for which You are currently enrolled. If You are not currently enrolled for Dependent Dental Insurance but You enroll or make changes to Your insurance during a subsequent enrollment period, the Dependent Dental Insurance takes effect on the first day of the month following the enrollment period, if You are Actively at Work on that day.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment Due to a Qualifying Event You may enroll for Dependent Insurance for which You are eligible or change the amount of Your Dependent Insurance between annual enrollment periods only if You have a Qualifying Event.

If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or changes to Your insurance made as a result of a Qualifying Event will take effect on the date of the Qualifying Event, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Qualifying Event includes:      

marriage; or the birth, adoption or placement for adoption of a dependent child; or divorce, legal separation or annulment; or the death of a dependent; or You previously did not enroll for dental coverage for You or Your dependent because You had other group coverage, but that coverage has ceased due to loss of eligibility for the other group coverage; or Your dependent's ceasing to qualify as a dependent under this insurance or under other group coverage.

DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS A Dependent's insurance will end on the earliest of: 1. the date Your Dental Insurance ends; 2. the date You die; 3. the date the Group Policy ends; 4. the date Insurance for Your Dependents ends under the Group Policy; 5. the date Insurance for Your Dependents ends for Your class; 6. the last day of the calendar month in which Your employment ends; Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT. GCERT2000 e/dep 37 ASPEN 2018 BENEFITS :: 178

ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (CONTINUED) 7. the end of the period for which the last premium has been paid; 8. the date the person ceases to be a Dependent except in the case of a Dependent Child who has reached the maximum age as defined in the DEFINITIONS section, Insurance will end on the last day of the calendar month; 9. for Utah residents, the last day of the calendar month the person ceases to be a Dependent; 10. the last day of the calendar month in which You retire in accordance with the Employer's retirement plan.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.

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SPECIAL RULES FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP DENTAL COVERAGE The following rules will apply if this Dental Insurance replaces other group dental coverage provided to You by the Employer.

Prior Plan means the group dental coverage provided to You by the Employer on the day before the Replacement Date.

Replacement Date means the effective date of this Dental Insurance under the Group Policy.

Rules if You and Your Dependents were Covered Under the Prior Plan on the Day Before the Replacement Date: 1. if You and Your Dependents were covered under the Prior Plan on the day before the Replacement Date, You will be eligible for this Dental Insurance on the Replacement Date if You are in an eligible class on such date; 2. if any of the following conditions occurred while coverage was in effect under the Prior Plan, We will treat such conditions as though they occurred while this Dental Insurance is in effect: 

the loss of a tooth; and



the accumulation of amounts toward: 

Annual Deductibles;



Annual Maximum Benefits;



Lifetime Maximum Benefits;

3. if a dental service was received while the Prior Plan was in effect and such service would be a Covered Service subject to frequency and/or time limitations if performed while this Dental Insurance is in effect, the receipt of such prior service will be counted toward the time and frequency limitations under this Dental Insurance; 4. if a government mandated continuation of coverage under the Prior Plan was in effect on the Replacement Date, such coverage may be continued under this Dental Insurance if the required payment is made for the cost of such coverage. In such case, benefits will be available under this Dental Insurance until the earlier of: 

the date the continued coverage ends as set forth in the provisions of the government-mandated requirements; or



the date this Dental Insurance ends.

Rules if You and Your Dependents were NOT covered under the Prior Plan on the Day Before the Replacement Date: 1. You will be eligible for this Dental Insurance when You meet the eligibility requirements for such insurance as described in ELIGIBILITY PROVISIONS: INSURANCE FOR YOU; 2. Your Dependents will be eligible for this Dental Insurance when they meet the eligibility requirements for such insurance as described in ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS; and 3. We will credit any time accumulated toward any eligibility waiting period under the Prior Plan to the satisfaction of any eligibility waiting period required to be met under this Dental Insurance.

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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN Insurance for a Dependent Child may be continued past the age limit if the child is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of such handicap must be sent to Us within 31 days after the date the Child attains the age limit and at reasonable intervals after such date, but not more frequently than once a year after the two-year period following the child’s attainment of the limiting age.

Subject to the DATE INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue while such Child: 

remains incapable of self-sustaining employment because of a mental or physical handicap; and



continues to qualify as a Child, except for the age limit.

FOR FAMILY AND MEDICAL LEAVE Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave Act of 1993 (FMLA), or other legally mandated leave of absence or similar laws. Please contact the Employer for information regarding such legally mandated leave of absence laws.

COBRA CONTINUATION FOR DENTAL INSURANCE The following applies to employers with 20 or more employees that are not church or government plans: If Dental Insurance for You or a Dependent ends, You or Your Dependent may qualify for continuation of such insurance under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA).

Please refer to the COBRA section of Your summary plan description or contact the Employer for information regarding continuation of insurance under COBRA. AT THE EMPLOYER’S OPTION The Employer has elected to continue insurance by paying premiums for employees who cease Active Work in an eligible class for any of the reasons specified below. If Your insurance is continued, insurance for Your Dependents may also be continued. You will be notified by the Employer how much You will be required to contribute.

Insurance will continue for the following periods: 1. for the period You cease Active Work in an eligible class due to layoff up to 2 months.

2. for the period You cease Active Work in an eligible class due to injury or sickness up to 9 months.

3. for the period You cease Active Work in an eligible class due to any other Employer approved leave of absence up to 2 months.

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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (CONTINUED) At the end of any of the continuation periods listed above, Your insurance will be affected as follows: 

if You resume Active Work in an eligible class at this time, You will continue to be insured under the Group Policy;



if You do not resume Active Work in an eligible class at this time, Your employment will be considered to end and Your insurance will end in accordance with the DATE YOUR INSURANCE ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU.

If Your insurance ends, Your Dependents’ insurance will also end in accordance with the DATE INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS.

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EVIDENCE OF INSURABILITY No evidence of insurability is required for the insurance described in this certificate.

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DENTAL INSURANCE If You or a Dependent incur a charge for a Covered Service, Proof of such service must be sent to Us. When We receive such Proof, We will review the claim and if We approve it, will pay the insurance in effect on the date that service was completed.

This Dental Insurance gives You access to Dentists through the MetLife Preferred Dentist Program (PDP).

Dentists participating in the PDP have agreed to limit their charge for a dental service to the Maximum Allowed Charge for such service. Under the PDP, We pay benefits for Covered Services performed by either In-Network Dentists or Out-of-Network Dentists. However, You may be able to reduce Your out-of-pocket costs by using an In-Network Dentist because Out-of-Network Dentists have not entered into an agreement with Us to limit their charges. You are always free to receive services from any Dentist. You do not need any authorization from Us to choose a Dentist.

The PDP does not provide dental services. Whether or not benefits are available for a particular service, does not mean You should or should not receive the service. You and Your Dentist have the right and are responsible at all times for choosing the course of treatment and services to be performed. After services have been performed, We will determine the extent to which benefits, if any, are payable.

When requesting a Covered Service from an In-Network Dentist, We recommend that You:  

identify Yourself as an insured in the Preferred Dentist Program; and confirm that the Dentist is currently an In-Network Dentist at the time that the Covered Service is performed.

The amount of the benefit will not be affected by whether or not You identify Yourself as a member in the Preferred Dentist Program.

You can obtain a customized listing of MetLife’s In-Network Dentists either by calling 1-800-275-4638 or by visiting Our website at www.metlife.com/dental.

BENEFIT AMOUNTS We will pay benefits in an amount equal to the Covered Percentage for charges incurred by You or a Dependent for a Covered Service as shown in the SCHEDULE OF BENEFITS, subject to the conditions set forth in this certificate.

In-Network If a Covered Service is performed by an In-Network Dentist, We will base the benefit on the Covered Percentage of the Maximum Allowed Charge.

If an In-Network Dentist performs a Covered Service, You will be responsible for paying:  

the Deductible; and any other part of the Maximum Allowed Charge for which We do not pay benefits.

Out-of-Network If a Covered Service is performed by an Out-of-Network Dentist, We will base the benefit on the Covered Percentage of the Maximum Allowed Charge.

Out-of-Network Dentists may charge You more than the Maximum Allowed Charge. If an Out-of-Network Dentist performs a Covered Service, You will be responsible for paying:   

the Deductible; any other part of the Maximum Allowed Charge for which We do not pay benefits; and any amount in excess of the Maximum Allowed Charge charged by the Out-of-Network Dentist.

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DENTAL INSURANCE (CONTINUED) Maximum Benefit Amounts The Schedule of Benefits sets forth Maximum Benefit Amounts We will pay for Covered Services received InNetwork and Out-of-Network. We will never pay more than the greater of the In-Network Maximum Benefit Amount or the Out-of-Network Maximum Benefit Amount.

For example, if a Covered Service is received Out-of-Network and We pay $300 in benefits for such service, $300 will be applied toward both the In-Network and the Out-of-Network Maximum Benefit Amounts applicable to such service.

Deductibles The Deductible amounts are shown in the Schedule of Benefits.

The Yearly Individual Deductible is the amount that You and each Dependent must pay for Covered Services to which such Deductible applies each Year before We will pay benefits for such Covered Services.

We apply amounts used to satisfy Yearly Individual Deductibles to the Yearly Family Deductible. Once the Yearly Family Deductible is satisfied, no further Yearly Individual Deductibles are required to be met.

The amount We apply toward satisfaction of a Deductible for a Covered Service is the amount We use to determine benefits for such service. The Deductible Amount will be applied based on when Dental insurance claims for Covered Services are processed by Us. The Deductible Amount will be applied to Covered Services in the order that Dental Insurance claims for Covered Services are processed by Us regardless of when a Covered Service is “incurred”. When several Covered Services are incurred on the same date and Dental Insurance benefits are claimed as part of the same claim, the Deductible Amount is applied based on the Covered Percentage applicable to each Covered Service. The Deductible Amount will be applied in the order of highest Covered Percentage to lowest Covered Percentage.

Alternate Benefit If We determine that a service, less costly than the Covered Service the Dentist performed, could have been performed to treat a dental condition, We will pay benefits based upon the less costly service if such service:  would produce a professionally acceptable result under generally accepted dental standards; and  would qualify as a Covered Service.

For example:   

when a filling and an inlay are both professionally acceptable methods for treating tooth decay or breakdown, We may base Our benefit determination upon the filling which is the less costly service; when a filling and a crown are both professionally acceptable methods for treating tooth decay or breakdown, We may base Our benefit determination upon the filling which is the less costly service; and when a partial denture and fixed bridgework are both professionally acceptable methods for replacing multiple missing teeth in an arch, We may base Our benefit determination upon the partial denture which is the less costly service.

If We pay benefits based upon a less costly service in accordance with this subsection, the Dentist may charge You or Your Dependent for the difference between the service that was performed and the less costly service. This is the case even if the service is performed by an In-Network Dentist.

Certain comprehensive dental services have multiple steps associated with them. These steps can be completed at one time or during multiple sessions. For benefit purposes under this certificate, these separate steps of one service are considered to be part of the more comprehensive service. Even if the dentist submits separate bills, the total benefit payable for all related charges will be limited by the maximum benefit payable for the more comprehensive service. For example, root canal therapy includes x-rays, opening of the pulp chamber, additional x-rays, and filling of the chamber. Although these services may be performed in multiple sessions, they all constitute root canal therapy. Therefore, we will only pay benefits for the root canal therapy.

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DENTAL INSURANCE (CONTINUED) Orthodontic Covered Services Orthodontic treatment generally consists of initial placement of an appliance and periodic follow-up visits.

The benefit payable for the initial placement will not exceed 20% of the Maximum Benefit Amount for Orthodontia.

The benefit payable for the periodic follow-up visits will be based on the lower of:  the amount charged by the Dentist; and  the Maximum Benefit Amount for Orthodontia.

The benefit payable for the periodic follow-up visits will be payable on a monthly basis during the scheduled course of the orthodontic treatment if:  Dental Insurance is in effect for the person receiving the orthodontic treatment; and  proof is given to Us that the orthodontic treatment is continuing.

Benefits for Orthodontic Services Begun Prior to this Dental Insurance If the initial placement was made prior to this Dental Insurance being in effect, the benefit payable will be reduced by the portion attributable to the initial placement.

If the periodic follow-up visits commenced prior to this Dental Insurance being in effect:  the number of months for which benefits are payable will be reduced by the number of months of treatment performed before this Dental Insurance was in effect; and  the total amount of the benefit payable for the periodic visits will be reduced proportionately.

Pretreatment Estimate of Benefits If a planned dental service is expected to cost more than $300, You have the option of requesting a pretreatment estimate of benefits. The Dentist should submit a claim detailing the services to be performed and the amount to be charged. After We receive this information, We will provide You with an estimate of the Dental Insurance benefits available for the service. The estimate is not a guarantee of the amount We will pay. Under the Alternate Benefit provision, benefits may be based on the cost of a service other than the service that You choose. You are required to submit Proof on or after the date the dental service is completed in order for Us to pay a benefit for such service.

The pretreatment estimate of benefits is only an estimate of benefits available for proposed dental services.

You are not required to obtain a pretreatment estimate of benefits. As always, You or Your Dependent and the Dentist are responsible for choosing the services to be performed.

Benefits We Will Pay After Insurance Ends We will pay benefits for a 31 day period after Your Insurance ends for the completion of installation of a prosthetic device if:  

the Dentist prepared the abutment teeth or made impressions before Your Insurance ends; and the device is installed within 31 days after the date the Insurance ends.

We will pay benefits for a 31 day period after Your Insurance ends for the completion of installation of a Cast Restoration if:  

the Dentist prepared the tooth for the Cast Restoration before Your Insurance ends; and the Cast Restoration is installed within 31 days after the date the Insurance ends.

We will pay benefits for a 31 day period after Your Insurance ends for completion of root canal therapy if:  

the Dentist opened into the pulp chamber before Your Insurance ends; and the treatment is finished within 31 days after the date the Insurance ends.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES Type A Covered Services 1. Oral exams are limited to once every 6 months less the number of problem-focused examinations received during such months.

2. Screenings, including state or federally mandated screenings, to determine an individual's need to be seen by a dentist for diagnosis, are limited to once every 6 months.

3. Patient assessments (limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment), are limited to once every 6 months.

4. Problem-focused examinations are limited to once every 6 months less the number of oral exams received during such months.

5. Bitewing x-rays but not more than 1 set every 12 months.

6. Full mouth or panoramic x-rays once every 60 months.

7. Intraoral-periapical x-rays.

8. Dental x-rays except as mentioned elsewhere in this certificate.

9. Cleaning of teeth also referred to as oral prophylaxis (including full mouth scaling in presence of generalized moderate or severe gingival inflammation after oral evaluation) once every 6 months.

10. Topical fluoride treatment for a Child under age 14, but not more than twice in 12 months.

11. Sealants or sealant repairs for a Child under age 16, which are applied to non-restored, non-decayed first and second permanent molars, but not more than once per tooth every 36 months.

12. Preventive resin restorations, which are applied to non-restored first and second permanent molars, but not more than once per tooth every 36 months.

13. Interim caries arresting medicament application applied to permanent bicuspids and 1st and 2nd molar teeth, but not more than once per tooth every 36 months.

14. Space maintainers for a Child under age 16, once per lifetime per tooth area.

15. Emergency palliative treatment to relieve tooth pain.

16. Fixed and removable appliances for correction of harmful habits.

Type B Covered Services 1. Pulp vitality, diagnostic photographs, and bacteriological studies for determination of bacteriologic agents.

2. Collection and preparation of genetic sample material for laboratory analysis and report, but no more than once per lifetime.

3. Diagnostic casts.

4. Protective (sedative) fillings.

5. Initial placement of amalgam fillings.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (CONTINUED) 6. Replacement of an existing amalgam filling, but only if:  

at least 24 months have passed since the existing filling was placed; or a new surface of decay is identified on that tooth.

7. Initial placement of resin fillings.

8. Replacement of an existing resin filling, but only if:  

at least 24 months have passed since the existing filling was placed; or a new surface of decay is identified on that tooth.

9. Consultations for interpretation of diagnostic image by a Dentist not associated with the capture of the image, but not more than once in a 12 month period.

10. Other consultations, but not more than once in a 12 month period.

11. General anesthesia or intravenous sedation in connection with oral surgery, extractions or other Covered Services, when We determine such anesthesia is necessary in accordance with generally accepted dental standards.

12. Simple extractions.

13. Surgical extractions.

14. Oral surgery except as mentioned elsewhere in this certificate.

15. Pulp capping (excluding final restoration).

16. Pulp therapy.

17. Apexification/recalcification.

18. Therapeutic pulpotomy (excluding final restoration).

19. Root canal treatment, including bone grafts and tissue regeneration procedures in conjunction with periradicular surgery, but not more than once for the same tooth.

Other endodontic procedures, such as apicoectomy, retrograde fillings, root amputation, and hemisection.

20. Periodontal maintenance where periodontal treatment (including scaling, root planing, and periodontal surgery such as gingivectomy, gingivoplasty and osseous surgery) has been performed. Periodontal maintenance is limited two times in any calendar year less the number of teeth cleanings received during such calendar year.

21. Periodontal, non-surgical treatment such as scaling and root planing, but not more than once per quadrant in any 24 month period.

22. Periodontal surgery not mentioned elsewhere, including gingivectomy, gingivoplasty and osseous surgery, but no more than one surgical procedure per quadrant in any 36 month period.

23. Periodontal soft & connective tissue grafts, but no more than one surgical procedure per quadrant in any 36 month period.

24. Prefabricated crown, but no more than one replacement for the same tooth surface within 24 months.

25. Occlusal adjustments, but not more than once in a 12 month period.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (CONTINUED) 26. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards including adjustments and night guards.

Type C Covered Services 1. Tissue Conditioning, but not more than once in a 12 month period.

2. Initial installation of Cast Restorations (except an implant supported Cast Restoration).

3. Replacement of Cast Restorations (except an implant supported Cast Restoration), but only if at least 10 years have passed since the most recent time that:  

a Cast Restoration was installed for the same tooth surface; or a Cast Restoration for the same tooth surface was replaced.

4. Simple Repairs of Cast Restorations but not more than once in a 12 month period.

5. Core buildup, but no more than once per tooth in a period of 10 calendar years.

6. Labial veneers, but no more than once per tooth in a period of 10 calendar years.

7. Post and cores, but no more than once per tooth in a period of 10 calendar years.

8. Initial installation of fixed and permanent Denture: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

9. Replacement of a non-serviceable fixed and permanent Denture if such Denture was installed more than 10 calendar years prior to replacement.

10. Initial installation of full or removable Dentures: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

11. Replacement of an immediate, temporary full Denture with a permanent full Denture if the immediate, temporary full Denture cannot be made permanent and such replacement is done within 12 months of the installation of the immediate, temporary full Denture.

12. Replacement of a non-serviceable full or removable Denture if such Denture was installed more than 10 calendar years prior to replacement.

13. Adjustments of Dentures: 

if at least 6 months have passed since the installation of the existing removable Denture; and



not more than once in any 12 month period.

14. Relinings and rebasings of existing removable Dentures:  

if at least 6 months have passed since the installation of the existing removable Denture; and not more than once in any 24 month period.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (CONTINUED) 15. Repair of Dentures but not more than once in a 12 month period.

16. Addition of teeth to fixed and permanent Denture to replace natural teeth.

17. Addition of teeth to a partial removable Denture to replace natural teeth.

18. Re-cementing of Cast Restorations or Dentures but not more than once in a 12 month period.

19. Implant services (including sinus augmentation and bone replacement and graft for ridge preservation), but no more than once for the same tooth position in a 10 calendar year period: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

20. Cleaning and inspection of a removable appliance once every 6 months.

21. Repair of implants, but not more than once in a 10 calendar year period.

22. Implant supported prosthetics, but no more than once for the same tooth position in a 10 calendar year period: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

23. Repair of implant supported prosthetics but not more than once in a 12 month period.

24. Local chemotherapeutic agents.

25. Injections of therapeutic drugs.

26. Application of desensitizing medicaments where periodontal treatment (including scaling, root planing, and periodontal surgery such as osseous surgery) has been performed.

27. Non-surgical treatment of temporomandibular joint disorders. This includes cone beam imaging but cone beam imaging for such treatment will not be covered more than once for the same tooth position in a 60 month period.

With respect to residents of Minnesota, Oral surgical and non-surgical treatment of Temporomandibular joint disorders (TMJ) and craniomandibular disorder. This includes cone beam imaging but cone beam imaging for such treatment will not be covered more than once for the same tooth position in a 60 month period.

Type D Covered Services Orthodontia, if the orthodontic appliance is initially installed while Dental Insurance is in effect for You, Your Spouse, and Your Children.

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DENTAL INSURANCE: EXCLUSIONS We will not pay Dental Insurance benefits for charges incurred for: 1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature; 2. Services for which You would not be required to pay in the absence of Dental Insurance; 3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 4. Services which are primarily cosmetic, unless required for the treatment or correction of a congenital defect of a newborn child.

5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: 

scaling and polishing of teeth; or



fluoride treatments.

6. Services or appliances which restore or alter occlusion or vertical dimension.

7. Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease.

8. Restorations or appliances used for the purpose of periodontal splinting.

9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.

10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.

11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.

12. Missed appointments.

13. Services: 

covered under any workers’ compensation or occupational disease law;



covered under any employer liability law;



for which the employer of the person receiving such services is not required to pay; or



received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

14. Services covered under other coverage provided by the Employer.

15. Temporary or provisional restorations.

16. Temporary or provisional appliances.

17. Prescription drugs.

18. Services for which the submitted documentation indicates a poor prognosis.

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DENTAL INSURANCE: EXCLUSIONS (CONTINUED) 19. Services, to the extent such services, or benefits for such services, are available under a Government Plan.

This exclusion will apply whether or not the person receiving the services is enrolled for the Government Plan. We will not exclude payment of benefits for such services if the Government Plan requires that Dental Insurance under the Group Policy be paid first.

Government Plan means any plan, program, or coverage which is established under the laws or regulations of any government.

The term does not include: 

any plan, program or coverage provided by a government as an employer; or



Medicare.

20. The following when charged by the Dentist on a separate basis: 

claim form completion;



infection control such as gloves, masks, and sterilization of supplies; or



local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.

21. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food.

22. Caries susceptibility tests.

23. Precision attachments, except when the precision attachment is related to implant prosthetics.

24. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it.

25. Repair or replacement of an orthodontic device.

26. Duplicate prosthetic devices or appliances.

27. Replacement of a lost or stolen appliance, Cast Restoration, or Denture.

28. Intra and extraoral photographic images.

GCERT2000 den/exclusions

51 ASPEN 2018 BENEFITS :: 192

DENTAL INSURANCE: COORDINATION OF BENEFITS COORDINATION OF THIS CONTRACT'S BENEFITS WITH OTHER BENEFITS The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one Plan. Plan is defined below. The order of benefit determination rules govern the order in which each Plan will pay a claim for benefits. The Plan that pays first is called the primary Plan.

The primary Plan must pay benefits in accord with its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the primary Plan is the secondary Plan. The secondary Plan may reduce the benefits it pays so that payments from all Plans equal 100 percent of the total Allowable Expense.

DEFINITIONS (a) A "Plan" is any of the following that provides benefits or services for dental care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same Plan and there is no COB among those separate contracts.

(1) Plan includes: group, blanket, or franchise accident and health insurance policies, excluding disability income protection coverage; individual and group health maintenance organization evidences of coverage; individual accident and health insurance policies; individual and group preferred provider benefit Plans and exclusive provider benefit Plans; group insurance contracts, individual insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care; dental care components of individual and group long-term care contracts; limited benefit coverage that is not issued to supplement individual or group in-force policies; uninsured arrangements of group or group-type coverage; the dental benefits coverage in automobile insurance contracts; and Medicare or other governmental benefits, as permitted by law.

(2) Plan does not include: disability income protection coverage; the Texas Health Insurance Pool; workers' compensation insurance coverage; hospital confinement indemnity coverage or other fixed indemnity coverage; specified disease coverage; supplemental benefit coverage; accident only coverage; specified accident coverage; school accident-type coverages that cover students for accidents only, including athletic injuries, either on a "24-hour" or a "to and from school" basis; benefits provided in long-term care insurance contracts for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care, and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services; Medicare supplement policies; a state Plan under Medicaid; a governmental Plan that, by law, provides benefits that are in excess of those of any private insurance Plan; or other nongovernmental Plan; or an individual accident and health insurance policy that is designed to fully integrate with other policies through a variable deductible.

Each contract for coverage under (a)(1) or (a)(2) is a separate Plan. If a Plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate Plan. (b) "This Plan" means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other Plans. Any other part of the contract providing health care benefits is separate from This Plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with like benefits, and may apply other separate COB provisions to coordinate other benefits.

The order of benefit determination rules determine whether This Plan is a primary Plan or secondary Plan when the person has health care coverage under more than one Plan. When This Plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits. When This Plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits equal 100 percent of the total allowable expense.

GCERT2000 den/cob 10/15

52 ASPEN 2018 BENEFITS :: 193

DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) (c) "Allowable expense" is a dental care expense, including deductibles, coinsurance, and copayments, that is covered at least in part by any Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any Plan covering the person is not an Allowable Expense. In addition, any expense that a provider by law in accordance with a contractual agreement is prohibited from charging a covered person is not an Allowable Expense.

The following are examples of expenses that are not Allowable Expenses:

(1) If a person is covered by two or more Plans that provide benefits or services on the basis of negotiated, an amount in excess of the highest of the negotiated fees is not an Allowable Expense.

(2) If a person is covered by one Plan that does not have negotiated fees and that calculates its benefits or services based on usual and customary fees, allowed amounts, relative value schedule reimbursement methodology, or other similar reimbursement methodology, and another Plan that provides its benefits or services based on negotiated fees, the primary Plan's payment arrangement must be the Allowable Expense for all Plans. However, if the health care provider or physician has contracted with the secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary Plan's payment arrangement and if the health care provider's or physician's contract permits, the negotiated fee or payment must be the Allowable Expense used by the secondary Plan to determine its benefits.

(3) The amount of any benefit reduction by the primary Plan because a covered person has failed to comply with the Plan provisions is not an Allowable Expense. Examples of these types of Plan provisions include second surgical opinions, prior authorization of admissions, and preferred provider arrangements. (d) "Allowed amount" is the amount of a billed charge that a carrier determines to be covered for services provided by a nonpreferred provider. The allowed amount includes both the carrier's payment and any applicable deductible, copayment, or coinsurance amounts for which the insured is responsible. (e) "Closed Panel Plan" is a Plan that provides dental care benefits to covered persons primarily in the form of services through a panel of health care providers and physicians that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other health care providers and physicians, except in cases of emergency or referral by a panel member. (f) "Custodial Parent" is the parent with the right to designate the primary residence of a child by a court order under the Texas Family Code or other applicable law, or in the absence of a court order, is the parent with whom the child resides more than one-half of the calendar year, excluding any temporary visitation.

When a person is covered by two or more Plans, the rules for determining the order of benefit payments are as follows: ORDER OF BENEFIT DETERMINATION RULES (a) The primary Plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other Plan. (b) Except as provided in (c), a Plan that does not contain a COB provision that is consistent with this policy is always primary unless the provisions of both Plans state that the complying Plan is primary.

GCERT2000 den/cob 10/15

53 ASPEN 2018 BENEFITS :: 194

DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) (c) Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage must be excess to any other parts of the Plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base Plan hospital and surgical benefits, and insurance type coverages that are written in connection with a Closed Panel Plan to provide out-ofnetwork benefits. (d) A Plan may consider the benefits paid or provided by another Plan in calculating payment of its benefits only when it is secondary to that other Plan. (e) If the primary Plan is a Closed Panel Plan and the secondary Plan is not, the secondary Plan must pay or provide benefits as if it were the primary Plan when a covered person uses a noncontracted health care provider or physician, except for emergency services or authorized referrals that are paid or provided by the primary Plan. (f) When multiple contracts providing coordinated coverage are treated as a single Plan under this subchapter, this section applies only to the Plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the Plan, the carrier designated as primary within the Plan must be responsible for the Plan's compliance with this subchapter. (g) If a person is covered by more than one secondary Plan, the order of benefit determination rules of this subchapter decide the order in which secondary Plans' benefits are determined in relation to each other. Each secondary Plan must take into consideration the benefits of the primary Plan or Plans and the benefits of any other Plan that, under the rules of this contract, has its benefits determined before those of that secondary Plan. (h) Each Plan determines its order of benefits using the first of the following rules that apply.

(1) Nondependent or Dependent. The Plan that covers the person other than as a dependent, for example as an employee, member, policyholder, subscriber, or retiree, is the primary Plan, and the Plan that covers the person as a dependent is the secondary Plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent and primary to the Plan covering the person as other than a dependent, then the order of benefits between the two Plans is reversed so that the Plan covering the person as an employee, member, policyholder, subscriber, or retiree is the secondary Plan and the other Plan is the primary Plan. An example includes a retired employee.

(2) Dependent Child Covered Under More Than One Plan. Unless there is a court order stating otherwise, Plans covering a Dependent Child must determine the order of benefits using the following rules that apply.

(A) For a Dependent Child whose parents are married or are living together, whether or not they have ever been married: (i) The Plan of the parent whose birthday falls earlier in the calendar year is the primary Plan; or (ii) If both parents have the same birthday, the Plan that has covered the parent the longest is the primary Plan.

(B) For a Dependent Child whose parents are divorced, separated, or not living together, whether or not they have ever been married: (i) if a court order states that one of the parents is responsible for the Dependent Child's health care expenses or health care coverage and the Plan of that parent has actual knowledge of those terms, that Plan is primary. This rule applies to Plan years commencing after the Plan is given notice of the court decree.

GCERT2000 den/cob 10/15

54 ASPEN 2018 BENEFITS :: 195

DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) (ii) if a court order states that both parents are responsible for the Dependent Child's health care expenses or health care coverage, the provisions of (h)(2)(A) must determine the order of benefits. (iii) if a court order states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the Dependent Child, the provisions of (h)(2)(A) must determine the order of benefits. (iv) if there is no court order allocating responsibility for the Dependent Child's health care expenses or health care coverage, the order of benefits for the Child are as follows: (I) the Plan covering the custodial parent; (II) the Plan covering the spouse of the custodial parent; (III) the Plan covering the noncustodial parent; then (IV) the Plan covering the spouse of the noncustodial parent.

(C) For a Dependent Child covered under more than one Plan of individuals who are not the parents of the Child, the provisions of (h)(2)(A) or (h)(2)(B) must determine the order of benefits as if those individuals were the parents of the Child.

(D) For a Dependent Child who has coverage under either or both parents' Plans and has his or her own coverage as a dependent under a spouse's Plan, (h)(5) applies.

(E) In the event the Dependent Child's coverage under the spouse's Plan began on the same date as the Dependent Child's coverage under either or both parents' Plans, the order of benefits must be determined by applying the birthday rule in (h)(2)(A) to the dependent Child's parent(s) and the dependent's spouse.]

(3) Active, Retired, or Laid-off Employee. The Plan that covers a person as an active employee, that is, an employee who is neither laid off nor retired, is the Primary Plan. The Plan that covers that same person as a retired or laid-off employee is the secondary Plan. The same would hold true if a person is a dependent of an active employee and that same person is a dependent of a retired or laid-off employee. If the Plan that covers the same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule does not apply. This rule does not apply if (h)(1) can determine the order of benefits.

(4) COBRA or State Continuation Coverage. If a person whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another Plan, the Plan covering the person as an employee, member, subscriber, or retiree or covering the person as a dependent of an employee, member, subscriber, or retiree is the primary Plan, and the COBRA, state, or other federal continuation coverage is the secondary Plan. If the other Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule does not apply. This rule does not apply if (h)(1) can determine the order of benefits.

(5) Longer or Shorter Length of Coverage. The Plan that has covered the person as an employee, member, policyholder, subscriber, or retiree longer is the primary Plan, and the Plan that has covered the person the shorter period is the secondary Plan.

(6) If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the Plans meeting the definition of Plan. In addition, This Plan will not pay more than it would have paid had it been the primary Plan.

GCERT2000 den/cob 10/15

55 ASPEN 2018 BENEFITS :: 196

DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) EFFECT ON THE BENEFITS OF THIS PLAN (a) When This Plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Plans are not more than the total allowable expenses. In determining the amount to be paid for any claim, the secondary Plan will calculate the benefits it would have paid in the absence of other health care coverage and apply that calculated amount to any allowable expense under its Plan that is unpaid by the primary Plan. The secondary Plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary Plan, the total benefits paid or provided by all Plans for the claim equal 100 percent of the total allowable expense for that claim. In addition, the secondary Plan must credit to its Plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage. (b) If a covered person is enrolled in two or more closed panel Plans and if, for any reason, including the provision of service by a nonpanel provider, benefits are not payable by one closed panel Plan, COB must not apply between that Plan and other closed panel Plans.

COMPLIANCE WITH FEDERAL AND STATE LAWS CONCERNING CONFIDENTIAL INFORMATION Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under This Plan and other Plans. We will comply with federal and state law concerning confidential information for the purpose of applying these rules and determining benefits payable under This Plan and other Plans covering the person claiming benefits. Each person claiming benefits under This Plan must give Us any facts it needs to apply those rules and determine benefits.

FACILITY OF PAYMENT A payment made under another Plan may include an amount that should have been paid under This Plan. If it does, We may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means the reasonable cash value of the benefits provided in the form of services.

RIGHT OF RECOVERY If the amount of the payments made by Us is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid or any other person or organization that may be responsible for the benefits or services provided for the covered person. The "amount of the payments made" includes the reasonable cash value of any benefits provided in the form of services.

GCERT2000 den/cob 10/15

56 ASPEN 2018 BENEFITS :: 197

FILING A CLAIM For Dental Insurance, all claim forms needed to file for benefits under the group insurance program can be obtained by calling MetLife at 1-800-275-4638. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim.

When We receive the claim form and Proof, We will review the claim and, if We approve it, We will pay benefits subject to the terms and provisions of this certificate and the Group Policy.

CLAIMS FOR DENTAL INSURANCE BENEFITS When a claimant files a claim for Dental Insurance benefits described in this certificate, both the notice of claim and the required Proof should be sent to Us within 90 days of the date of a loss.

Claim and Proof may be given to Us by following the steps set forth below: Step 1 A claimant can request a claim form by calling Us at 1-800-275-4638.

Step 2 We will send a claim form to the claimant within 15 days of the request. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim.

Step 3 When the claimant receives the claim form the claimant should fill it out as instructed and return it with the required Proof described in the claim form.

Step 4 The claimant must give Us Proof not later than 90 days after the date of the loss.

If notice of claim or Proof is not given within the time limits described in this section, the delay will not cause a claim to be denied or reduced if such notice and Proof are given as soon as is reasonably possible.

Time Limit on Legal Actions. A legal action on a claim for Dental Insurance benefits may only be brought against Us during a certain period. This period begins 60 days after the date Proof is filed and ends 3 years after the date such Proof is required.

GCERT2000 claim 10/04 57 ASPEN 2018 BENEFITS :: 198

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS Procedures for Presenting Claims for Dental Insurance Benefits All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Routine Questions on Dental Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-800-275-4638.

Claim Submission For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination After You submit a claim for Dental Insurance benefits to MetLife, MetLife will notify You acknowledging receipt of Your claim, commence with any investigation, and request any additional information within 15 days of receipt of Your claim.

MetLife will notify You in writing of the acceptance or rejection of Your claim within 15 business days of receipt of all information needed to process Your claim.

If MetLife cannot accept or reject Your claim within 15 business days after receipt of all information, MetLife will notify You within 15 business days stating the reason why we require an extension. If an extension is requested, We will notify You of our decision to approve or deny Your claim within 45 days. Upon notification of approval, Your claim will be paid within 5 business days.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Appealing the Initial Determination If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision. Appeals must be in writing and must include at least the following information:     

Name of Employee Name of the Plan Reference to the initial decision Whether the appeal is the first or second appeal of the initial determination An explanation why You are appealing the initial determination.

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

GCERT2000 den/claimrev

58 ASPEN 2018 BENEFITS :: 199

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS (CONTINUED) After MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials, and MetLifeâ&#x20AC;&#x2122;s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify You in writing of its final decision within 30 days after MetLifeâ&#x20AC;&#x2122;s receipt of Your written request for review, except that under special circumstances MetLife may have up to an additional 30 days to provide written notification of the final decision. If such an extension is required, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason(s) why such an extension is needed, and state when it will make its determination.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

GCERT2000 den/claimrev

59 ASPEN 2018 BENEFITS :: 200

GENERAL PROVISIONS Assignment The rights and benefits under the Group Policy are not assignable prior to a claim for benefits, except as required by law.

Upon receipt of a Covered Service, You may assign Dental Insurance benefits to the Dentist providing such service.

Dental Insurance: Who We Will Pay If You assign payment of Dental Insurance benefits to Your or Your Dependentâ&#x20AC;&#x2122;s Dentist, We will pay benefits directly to the Dentist. Otherwise, We will pay Dental Insurance benefits to You. Entire Contract Your insurance is provided under a contract of group insurance with the Employer. The entire contract with the Employer is made up of the following: 1. the Group Policy and its Exhibits, which include the certificate(s); 2. the Employer's application; and 3. any amendments and/or endorsements to the Group Policy.

Incontestability: Statements Made by You Any statement made by You will be considered a representation and not a warranty. We will not use such statement to avoid insurance, reduce benefits or defend a claim unless the following requirements are met: 1. the statement is in a Written application or enrollment form; 2. You have Signed the application or enrollment form; and 3. a copy of the application or enrollment form has been given to You or Your Beneficiary.

Misstatement of Age If Your age is misstated, the correct age will be used to determine if insurance is in effect and, as appropriate, We will adjust the benefits and/or premiums.

Conformity with Law If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be interpreted to so conform.

Autopsy We have the right to make a reasonable request for an autopsy where permitted by law. Any such request will set forth the reasons We are requesting the autopsy.

Overpayments Recovery of Dental Insurance Overpayments We have the right to recover any amount that We determine to be an overpayment, whether for services received by You or Your Dependents.

GCERT2000 gp 10/04

60 ASPEN 2018 BENEFITS :: 201

GENERAL PROVISIONS (CONTINUED) An overpayment occurs if We determine that: 

the total amount paid by Us on a claim for Dental Insurance is more than the total of the benefits due to You under this certificate; or



payment We made should have been made by another group plan.

If such overpayment occurs, You have an obligation to reimburse Us. How We Recover Overpayments We may recover the overpayment from You by:   

stopping or reducing any future benefits payable for Dental Insurance; demanding an immediate refund of the overpayment from You; and taking legal action.

We may recover such overpayment in accordance with that agreement.

If the overpayment results from Our having made a payment to You that should have been made under another group plan, We may recover such overpayment from one or more of the following:   

any other insurance company; any other organization; or any person to or for whom payment was made.

GCERT2000 gp 10/04

61 ASPEN 2018 BENEFITS :: 202

"THIS IS THE END OF THE CERTIFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION"

ASPEN 2018 BENEFITS :: 203

THIS SUMMARY PLAN DESCRIPTION IS EXPRESSLY MADE PART OF THE PLAN AND IS LEGALLY ENFORCEABLE AS PART OF THE PLAN WITH RESPECT TO ITS TERMS AND CONDITIONS. IN THE EVENT THERE IS NO OTHER PLAN DOCUMENT, THIS DOCUMENT SHALL SERVE AS A SUMMARY PLAN DESCRIPTION AND SHALL ALSO CONSTITUTE THE PLAN.

ERISA INFORMATION NAME OF THE PLAN BRG Management Inc dba Aspen Heights Welfare Benefit Plan ("Plan") NAME AND ADDRESS OF EMPLOYER BRG Management Inc dba Aspen Heights 1301 S Capital of Texas Hwy Austin, TX 78746 (512) 369-3030 EMPLOYER IDENTIFICATION NUMBER: 262458511 COVERAGE

PLAN NAME

Dental Insurance

BRG Management Inc dba Aspen Heights Welfare Benefit Plan

TYPE OF ADMINISTRATION The above listed benefits are insured by Metropolitan Life Insurance Company ("MetLife").

PLAN ADMINISTRATOR NAME, BUSINESS ADDRESS AND PHONE NUMBER BRG Management Inc dba Aspen Heights 1301 S Capital of Texas Hwy Austin, TX 78746 (512) 369-3030 AGENT FOR SERVICE OF LEGAL PROCESS For disputes arising under the Plan, service of legal process may be made upon the Plan Administrator at the above address. For disputes arising under those portions of the Plan insured by MetLife, service of legal process may be made upon MetLife at one of its local offices, or upon the supervisory official of the Insurance Department in the state in which you reside.

ELIGIBILITY FOR PARTICIPATION; DESCRIPTION OR SUMMARY OF BENEFITS Your MetLife certificate describes the eligibility requirements for insurance provided by MetLife under the Plan. It also includes a detailed description of the insurance provided by MetLife under the Plan.

ASPEN 2018 BENEFITS :: 204

The following applies to employers with 20 or more employees that are not church or government plans: NOTICE OF YOUR RIGHT AND YOUR DEPENDENTS' RIGHT TO COBRA CONTINUATION COVERAGE COBRA is a federal law that requires most group health plans to give their employees and their dependents the opportunity to continue coverage when coverage is terminated due to certain specific events. If your employment terminates for any reason other than your gross misconduct, or if your hours worked are reduced so that your coverage terminates, you and your covered dependents may be able to continue coverage under This Plan for a period of up to 18 months. If it is determined under the terms of the Social Security Act that You or your covered dependent is disabled within the first 60 days of COBRA coverage, you and your covered dependents may be able to continue your dental coverage under This Plan for an additional 11 months after the expiration of the 18 month period. In addition, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents may be able to continue coverage under This Plan for up to 36 months. Also, your covered children may be able to continue coverage under This Plan for up to 36 months after they no longer qualify as covered dependents under the terms of This Plan. Group health plans for employers with fewer than 20 employees, church plans, and plans established and maintained by the federal government are not subject to COBRA continuation requirements.

During the continuation period, a child of yours that is (1) born; (2) adopted by you; or (3) placed with you for adoption, will be treated as if the child were a covered dependent at the time coverage was lost due to an event described above.

This continuation will terminate on the earliest of: a. the end of the 18, 29 or 36 month continuation period, as the case may be; b. the date of expiration of the last period for which the required payment was made; c.

the date, after you or your covered dependent elects to continue coverage, that you or your covered dependent first becomes covered under another group health plan as long as the new plan does not contain any exclusion or limitation with respect to your or your covered dependentâ&#x20AC;&#x2122;s preexisting condition;

d. the date your employer ceases to provide any group health plan for its employees.

Notice will be given when you or your covered dependent becomes entitled to continue coverage under This Plan. You or your covered dependent will then have 60 days to elect to continue coverage. If you or your covered dependent do not notify your Employer within the 60-day election period, you will lose the option to elect continuation coverage.

Each person who is eligible for COBRA coverage is entitled to make a separate election of COBRA coverage.

Thus, a covered spouse (as defined by federal law) or dependent child (or parent on their behalf) is entitled to elect COBRA coverage even if the covered Employee does not make that election. However, covered Employees may elect COBRA coverage on behalf of their covered dependents. Any person who elects to continue coverage under This Plan must pay the full cost of that coverage (including both the share you now pay and the share your Employer now pays), plus any additional amounts permitted by law. Your payments for continued coverage must be made on the first day of each month in advance.

If you do not elect COBRA coverage, your dental coverage will end. However, if you initially waive COBRA continuation coverage before the end of the 60-day election period, you may change your election by sending the completed election form to the Plan Administrator and postmarking it no later than the last day of the 60day election period.

If You Elect Cobra If you choose COBRA coverage and pay the required premiums, you are entitled to coverage which, as of the time coverage is being provided, is identical to the coverage provided by the Employer to similarly situated active Employees, spouses or dependent children. This means that if the coverage for similarly situated Employees, spouses or dependent children changes, coverage will change for those who elected COBRA coverage.

ASPEN 2018 BENEFITS :: 205

Duration Of Cobra Coverage The law requires that you be given the opportunity to maintain COBRA coverage for 36 months from the date coverage ends as a result of the qualifying event unless you lost coverage because of the covered Employee's termination of employment or reduction in hours. In that case, the required COBRA coverage period is 18 months from the date you lose coverage as a result of the termination of employment or reduction in hours. However, the 18-month coverage period may be extended under the following circumstances: Disability. If any person entitled to COBRA coverage (the covered Employee, covered spouse or covered dependent child) is determined by the Social Security Administration to have been disabled at any time during the first 60 days of COBRA coverage period and the disability lasts at least until the end of the 18 month period of continuation coverage, then all such persons entitled to elect COBRA coverage may be able to continue coverage for up to 29 months, rather than 18 months.

In order to be eligible for the additional 11 months of COBRA coverage, the covered Employee, covered spouse or covered dependent child must notify the Employer's COBRA Administrator within 60 days of the latest of: (1) the Social Security Administration’s determination of disability; (2) the date of the qualifying event; (3) the date on which the covered Employee’s coverage initially was or will be lost; or (4) the date a person entitled to COBRA coverage is informed of this obligation by being provided the initial COBRA notice for the applicable group health plan. Written notice to the COBRA Administrator must be received before the end of the initial 18-month coverage period. A copy of the Social Security Administration’s determination must be provided to the COBRA Administrator. If these procedures are not followed, there will be no disability extension of COBRA. During the additional 11 months of coverage, your cost for that coverage will be approximately 50% higher than it was during the preceding 18 months.

The additional 11 months of coverage provided on account of a disability will end as of the earlier of: 

The first day of the month beginning more than 30 days after a final determination by the Social Security Administration that the disability no longer exists; or



The last day of the 29th month of total coverage.

A person entitled to COBRA coverage must notify the COBRA Administrator within 30 days if the Social Security Administration determines that the disabled person is no longer disabled. This Plan reserves the right to retroactively cancel COBRA coverage, and will require reimbursement of all benefits paid for claims incurred after coverage terminates.

Subsequent Qualifying Events. If, during the 18-month period of COBRA coverage (or within the 29-month maximum coverage period in the case of a disability extension), the covered Employee and the spouse divorce, the covered Employee dies, the covered Employee becomes entitled to Medicare, or a dependent ceases to be an eligible dependent under the terms of This Plan, then the covered spouse and/or covered dependent child(ren) (as applicable) may be able to extend COBRA coverage for up to 36 months from the date of the termination of employment or reduction in hours.

A person entitled to COBRA coverage must notify the Employer’s COBRA Administrator of the subsequent event no later than 60 days after its occurrence. If such notification is not given, the covered spouse and/or covered dependent child will not be entitled to the additional COBRA coverage.

Premiums For Cobra Coverage A person entitled to COBRA coverage is entirely responsible for paying the premiums for COBRA coverage.

The required payment for each continuation coverage period for each option will be described in the notice that is sent when an individual experiences a qualifying event.

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Initial Premium Payment If continuation of coverage is elected, payment for continuation coverage must be made no later than 45 days after the date of such election. (This is the date the election notice is post-marked, if mailed.) If the first payment for continuation coverage is not made in full by the 45th day after the date of election, continuation coverage under This Plan will end. A person entitled to COBRA coverage is responsible for making sure that the amount of the first payment is correct.

After the first payment for continuation coverage, the amount due for each coverage period for each qualified beneficiary will be provided when coverage is elected.

PLAN TERMINATION OR CHANGES Written notice of termination must be given to the Employer at least 31 days prior to the date such insurance will be terminated.

Premiums are due and payable on the first day of each month for which insurance coverage is to be provided.

If a payment is not received within 31 days after the due date, coverage will terminate as follows: a. with respect to coverages other than Life Insurance and Accidental Death or Dismemberment Insurance on the earlier of the 31st day following the due date and the date requested in writing by the Employer, provided such request is made before such 31st day; and b. with respect to Life Insurance and Accidental Death or Dismemberment Insurance -- on the later of the 31st day following the due date and the date MetLife's written notice of termination is received by the Employer.

The Employer is liable to MetLife for payment of the pro-rata premium which accrues while any coverage remains in force.

The group policy sets forth those situations in which the Employer and/or MetLife have the right to end the policy.

The Employer reserves the right to change or terminate the Plan at any time. Therefore, there is no guarantee that you will be eligible for the benefits described herein for the duration of your employment. Any such action will be taken only after careful consideration.

Your consent or the consent of your beneficiary is not required to terminate, modify, amend, or change the Plan.

In the event Your coverage ends in accord with the Date Your Insurance Ends provision of Your certificate, you may still be eligible to receive benefits. The circumstances under which benefits are available are described in Your MetLife certificate.

CONTRIBUTIONS You must make a contribution to the cost of Personal and Dependent Dental Insurance.

The total premium rate for insurance provided under the Plan by MetLife is set by MetLife.

PLAN YEAR The Plan's fiscal records are kept on a Plan year basis beginning each January 01 and ending on the following December 31.

Qualified Domestic Relations Orders/Qualified Medical Child Support Orders You and your beneficiaries can obtain, without charge, from the Plan Administrator a copy of any procedures governing Qualified Domestic Relations Orders (QDRO) and Qualified Medical Child Support Orders (QMCSO).

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Dental Benefits Claims Procedures for Presenting Claims for Dental Benefits All claim forms needed to file for benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist you or, if applicable, your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental.

Routine Questions If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1800-275-4638.

Claim Submission For claims for dental benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the Filing a Claim section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination After you submit a claim for dental benefits to MetLife, MetLife will review your claim and notify you of its decision to approve or deny your claim.

Such notification will be provided to you within a 30 day period from the date you submitted your claim; except for situations requiring an extension of time of up to 15 days because of matters beyond the control of the Plan. If MetLife needs such an extension, MetLife will notify you prior to the expiration of the initial 30 day period, state the reason why the extension is needed, and state when it will make its determination. If an extension is needed because you did not provide sufficient information or filed an incomplete claim, the time from the date of MetLife's notice requesting further information and an extension until MetLife receives the requested information does not count toward the time period MetLife is allowed to notify you as to its claim decision. You will have 45 days to provide the requested information from the date you receive the notice requesting further information from MetLife.

If MetLife denies your claim in whole or in part, the notification of the claims decision will state the reason why your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that you may request a copy free of charge.

Appealing the Initial Determination If MetLife denies your claim, you may take two appeals of the initial determination. Upon your written request, MetLife will provide you free of charge with copies of documents, records and other information relevant to your claim. You must submit your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife's decision. Appeals must be in writing and must include at least the following information: 

Name of Employee



Name of the Plan



Reference to the initial decision



Whether the appeal is the first or second appeal of the initial determination



An explanation why you are appealing the initial determination

As part of each appeal, you may submit any written comments, documents, records, or other information relating to your claim.

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After MetLife receives your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of your claim. Deference will not be given to initial denials, and MetLife's review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that you submit relating to your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review your appeal will not be the same person as the person who made the initial decision to deny your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify you in writing of its final decision within 30 days after MetLife's receipt of your written request for review, except that under special circumstances MetLife may have up to an additional 30 days to provide written notification of the final decision. If such an extension is required, MetLife will notify you prior to the expiration of the initial 30 day period, state the reason(s) why such an extension is needed, and state when it will make its determination.

If MetLife denies the claim on appeal, MetLife will send you a final written decision that states the reason(s) why the claim you appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that you may request a copy free of charge.

Upon written request, MetLife will provide you free of charge with copies of documents, records and other information relevant to your claim.

When the claim has been processed, you will be notified of the benefits paid. If any benefits have been denied, you will receive a written explanation.

Urgent Care Claim Submission A small number of claims for dental benefits may be urgent care claims. Urgent care claims for dental benefits are claims for reimbursement of dental expenses for services which a dentist familiar with the dental condition determines would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Of course any such claim may always be submitted in accordance with the normal claim procedures. However your dentist may also submit such a claim to MetLife by telephoning MetLife and informing MetLife that the claim is an Urgent Care Claim. Urgent Care Claims are processed according to the procedures set out above, however once a claim for urgent care is submitted, MetLife will notify you of the determination on the claim as soon as possible, but no later than 72 hours after the claim was filed. If you or your covered dependent does not provide the claims administrator with enough information to decide the claim, MetLife will notify you within 24 hours after it receives the claim of the further information that is needed. You will have 48 hours to provide the information. If the needed information is provided, MetLife will then notify you of the claim decision within 48 hours after MetLife received the information. If the needed information is not provided, MetLife will notify you or your covered dependent of its decision within 120 hours after the claim was received.

If your urgent care claim is denied but you receive the care, you may appeal the denial using the normal claim procedures. If your urgent care claim is denied and you do not receive the care, you can request an expedited appeal of your claim denial by phone or in writing. MetLife will provide you any necessary information to assist you in your appeal. MetLife will then notify you of its decision within 72 hours of your request in writing. However, MetLife may notify you by phone within the time frames above and then mail you a written notice.

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Discretionary Authority of Plan Administrator and Other Plan Fiduciaries In carrying out their respective responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

STATEMENT OF ERISA RIGHTS The following statement is required by federal law and regulation.

As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan administrator's office and at other specified locations, all Plan documents governing the Plan, including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefit Security Administration.

Obtain, upon written request to the Plan administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the Plan's annual financial report. The Plan administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue Group Dental Plan Insurance Continue dental insurance for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.

Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.

No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan administrator to provide the materials and pay you up to $110.00 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court.

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In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court.

If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court.

The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees.

If you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is frivolous.

Assistance with Your Questions If you have any questions about your Plan, you should contact the Plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

PLAN PRIVACY INFORMATION Notwithstanding any other Plan provision in this or other sections of the Plan, the Plan will operate in accordance with the HIPAA privacy laws and regulations as set forth in 45 CFR Parts 160 and 164, and as they may be amended ("HIPAA"), with respect to protected health information ("PHI") as that term is defined therein. The Plan Administrator and/or his or her designee retains full discretion in interpreting these rules and applying them to specific situations. All such decisions shall be given full deference unless the decision is determined to be arbitrary and capricious.

The term “Plan Sponsor” means BRG Management Inc. The term “Plan Administrator” means the entity designated as Plan Administrator by the Plan documents pursuant to which the plan is operated. If a Plan Administrator is not designated by the plan documents, the Plan Sponsor shall be deemed to be the Plan Administrator.

I. Permitted Uses and Disclosures of PHI by the Plan and the Plan Sponsor The Plan and the Plan Sponsor are permitted to use and disclose PHI for the following purposes, to the extent they are not inconsistent with HIPAA: 

For general plan administration, including policyholder service functions, enrollment and eligibility functions, reporting functions, auditing functions, financial and billing functions, to assist in the administration of a consumer dispute or inquiry, and any other authorized insurance or benefit function.



As required for computer programming, consulting or other work done in respect to the computer programs or systems utilized by the Plan.



Other uses relating to plan administration, which are approved in writing by the Plan Administrator.



At the request of an individual, to assist in resolving claims the individual may have with respect to benefits under the Plan.

ASPEN 2018 BENEFITS :: 211

II. Uses and Disclosures of PHI by the Plan and the Plan Sponsor for Required Purposes The Plan and Plan Sponsor may use or disclose PHI for the following required purposes: 

Judicial and administrative proceedings, in response to lawfully executed process, such as a court order or subpoena.



For public health and health oversight activities, and other governmental activities accompanied by lawfully executed process.



As otherwise may be required by law.

III. Sharing of PHI With the Plan Sponsor

As a condition of the Plan Sponsor receiving PHI from the Plan, the Plan Documents have been amended to incorporate the following provisions, under which the Plan Sponsor agrees to: 

Not use or further disclose PHI other than as permitted or required by the plan documents in Sections I and II above;



Ensure that any agents to whom it provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor;



Not use or disclose PHI for employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor;



Report to the Plan any use or disclosure of the information that is inconsistent with the permitted uses or disclosures of which it becomes aware;



Make PHI available to Plan participants for the purposes of the rights of access and inspection, amendment, and accounting of disclosures as required by HIPAA;



Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the Plan with HIPAA;



If feasible, return or destroy all PHI received from the Plan that the sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible;



Ensure that adequate separation between the Plan and Plan Sponsor is established in accordance with the following requirements: (A) Employees to be Given Access to PHI: The following employees (or class of employees) of the Plan Sponsor are the only individuals that may access PHI provided by the Plan: Human Resource Director (B) Restriction to Plan Administration Functions: The access to and use of PHI by the employees of the Plan Sponsor designated above will be limited to plan administration functions that the Plan Sponsor performs for the Plan.

(C) Mechanism for Resolving issues of Noncompliance: If the Plan Administrator determines that an employee of the Plan Sponsor designated above has acted in noncompliance with the plan document provisions outlined above, then the Plan Administrator shall take or seek to have taken appropriate disciplinary action with respect to that employee, up to and including termination of employment as ASPEN 2018 BENEFITS :: 212

appropriate. The Plan Administrator shall also document the facts of the violation, actions that have been taken to discipline the offending party and the steps taken to prevent future violations.

Certify to the Plan, prior to the Plan permitting disclosure of PHI to the Plan Sponsor, that the Plan Documents have been amended to incorporate the provisions in this Section.

IV. Security As a condition of the Plan Sponsor receiving electronic PHI (“ePHI”) from the Plan, the Plan Documents have been amended to incorporate the following provisions, under which the Plan Sponsor agrees to: 

Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the ePHI that it creates, receives, maintains, or transmits on behalf of the Plan;



Ensure that the adequate separation between the Plan and the Plan Sponsor, which is required by the applicable section(s) of the Plan relating to the sharing of PHI with the Plan Sponsor, is supported by reasonable and appropriate security measures;



Ensure that any agent to whom it provides ePHI agrees to implement reasonable and appropriate security measures to protect the information; and



Report to the Plan any security incident of which it becomes aware. In this context, the term “security incident” means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in information systems such as hardware, software, information, data, applications, communications, and people.

FUTURE OF THE PLAN

It is hoped that This Plan will be continued indefinitely, but BRG Management Inc dba Aspen Heights reserves the right to change or terminate the Plan in the future. Any such action would be taken only after careful consideration.

ASPEN 2018 BENEFITS :: 213

ASPEN 2018 BENEFITS :: 214

Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally.

Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals.

Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access.

We comply with all laws that apply to us.

Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses.

How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.

Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to:       

administer your products and services process claims and other transactions perform business research confirm or correct your information market new products to you help us run our business comply with applicable laws

Sharing Your Information With Others We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.

Other reasons we may share your information include:    

doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) telling another company what we know about you if we are selling or merging any part of our business giving information to a governmental agency so it can decide if you are eligible for public benefits giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account)

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  

giving your information to your health care provider having a peer review organization evaluate your information, if you have health coverage with us those listed in our “Using Your Information” section above HIPAA

We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance.

Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you.

You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. Select “Privacy Policy” at the bottom of the home page. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAprivacyAmericasUS@metlife.com, or call us at telephone number (212) 578-0299.

Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law.

If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife.

Questions/More Information We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us.

When you write, include your name, address, and policy or account number.

Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI 02887-9954 privacy@metlife.com We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies: Metropolitan Life Insurance Company MetLife Insurance Company USA SafeGuard Health Plans, Inc.

MetLife Health Plans, Inc. General American Life Insurance Company SafeHealth Life Insurance Company

CPN-Group-Ann-2015 ASPEN 2018 BENEFITS :: 216

Uniformed Services Employment And Reemployment Rights Act This section describes the right that you may have to continue coverage for yourself and your covered dependents under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).

Continuation of Group Dental Insurance: If you take a leave from employment for “service in the uniformed services,” as that term is defined in USERRA, and as a consequence your dental insurance coverage under your employer’s group dental insurance policy ends, you may elect to continue dental insurance for yourself and your covered dependents, for a limited period of time, as described below.

The law requires that your employer notify you of your rights, benefits and obligations under USERAA including instructions on how to elect to continue insurance, the amount and procedure for payment of premium. If permitted by USERRA, your employer may require that you elect to continue coverage within a period of time specified by your employer.

You may be responsible for payment of the required premium to continue insurance. If your leave from employment for service in the uniformed services lasts less than 31 days, your required premium will be no more than the amount you were required to pay for dental insurance before the leave began; for a leave lasting 31 or more days, you may be required to pay up to 102% of the total dental insurance premium, including any amount that your employer was paying before the leave began.

You and your covered dependents insurance that is continued pursuant to USERRA will end on the earliest of the following:  

the end of 24 consecutive months from the date your leave from employment for service in the uniformed services begins; or the day after the date on which you fail to apply for, or return to employment, in accordance with USERRA.

You and your covered dependent may become entitled to continuation of coverage under the Consolidated Omnibus Budget Reconciliation Act (“COBRA”) while you have dental insurance coverage under your employer’s group dental insurance policy pursuant to USERRA. Contact your employer for more information.

ASPEN 2018 BENEFITS :: 217

Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188

CERTIFICATE OF INSURANCE Metropolitan Life Insurance Company ("MetLife"), a stock company, certifies that You and Your Dependents are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY. This certificate is part of the Group Policy. The Group Policy is a contract between MetLife and the Employer and may be changed or ended without Your consent or notice to You. This certificate describes insurance provided by a certificate previously issued to You by MetLife and replaces such previous certificate.

Employer:

BRG Management Inc dba Aspen Heights

Group Policy Number:

KM 05932994-G

Type of Insurance:

Dental Insurance

MetLife Toll Free Number(s): For General Information

1-800-275-4638

THIS CERTIFICATE ONLY DESCRIBES DENTAL INSURANCE. FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED. THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE LAW OF A STATE OTHER THAN FLORIDA. THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS REQUIRED BY MARYLAND LAW. WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) CAREFULLY.

GCERT2000 fp

All Active Full-Time Employees who elect the High Option Dental Plan RV 01/10/2017 1 ASPEN 2018 BENEFITS :: 218

IMPORTANT NOTICE

AVISO IMPORTANTE

To obtain information or make a complaint:

Para obtener información o para presentar una queja:

You may call MetLife’s toll free telephone number for information or to make a complaint at:

Usted puede llamar al número de teléfono gratuito de MetLife’s para obtener información o para presentar una queja al:

1-800-275-4638 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights, or complaints at:

1-800-252-3439

1-800-275-4638 Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre compañías, coberturas, derechos o quejas al:

1-800-252-3439

You may write the Texas Department of Insurance:

Usted puede escribir al Departamento de Seguros de Texas a:

P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007

P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007

Web: www.tdi.texas.gov

Sitio web: www.tdi.texas.gov

E-mail: ConsumerProtection@tdi.texas.gov

E-mail: ConsumerProtection@tdi.texas.gov

PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact MetLife first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

DISPUTAS POR PRIMAS DE SEGUROS O RECLAMACIONES: Si tiene una disputa relacionada con su prima de seguro o con una reclamación, usted debe comunicarse con MetLife primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas.

ATTACH THIS NOTICE TO YOUR CERTIFICATE: This notice is for information only and does not become a part or condition of the attached document.

ADJUNTE ESTE AVISO A SU CERTIFICADO: Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto.

GCERT2000 notice/tx 02/15

For Texas Residents 2 ASPEN 2018 BENEFITS :: 219

NOTICE FOR RESIDENTS OF ALASKA Reasonable and Customary Charges Reasonable and Customary Charges for Out-of-Network services will not be based less than an 80th percentile of the dental charges.

Reasonable Access to an In-Network Dentist If You do not have an In-Network Dentist within 50 miles of Your legal residence, We will reimburse You for the cost of Covered Services and materials provided by an Out-of-Network Dentist at the same benefit level as an In-Network Dentist.

Coordination of Benefits or Non-Duplication of Benefits with a Secondary Plan: If This Plan is Secondary, This Plan will determine benefits as if the services were obtained from This Plan’s In-Network provider under the following circumstances:   

the Primary Plan does not provide benefits through a provider network; both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains services through a provider in the Primary plan’s network who is not in This Plan’s network; or both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains services from a provider that is not part of the provider network of the Primary Plan or This Plan because no provider in the Primary Plan’s provider network or This Plan’s network is able to meet the particular health need of the covered person.

Procedures For Dental Claims Procedures for Presenting Claims for Dental Insurance Benefits All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Routine Questions on Dental Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1800-275-4638.

Claim Submission For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination After You submit a claim for Dental Insurance benefits to MetLife, MetLife will review Your claim and notify You of its decision to approve or deny Your claim.

Such notification will be provided to You within a 30 day period from the date You submitted Your claim; except for situations requiring an extension of time of up to 15 days because of matters beyond the control of MetLife. If MetLife needs such an extension, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason why the extension is needed, and state when it will make its determination. If an extension is needed because You did not provide sufficient information or filed an incomplete claim, the time from the date of MetLife’s notice requesting further information and an extension until MetLife receives the requested information does not count toward the time period MetLife is allowed to notify You as to its claim GCERT2000 notice/ak

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NOTICE FOR RESIDENTS OF ALASKA decision. You will have 45 days to provide the requested information from the date You receive the notice requesting further information from MetLife.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Within 30 days after We receive Proof of Your claim, We will approve and pay the claim or We will deny the claim. If We deny the claim, We will provide You with the basis of Our denial or the specific additional information that We need to adjudicate Your claim. If We request additional information, We will approve and pay the claim or We will deny the claim within 15 days after We receive the additional information. If the claim is approved and not paid within the time period provided, the claim will accrue at an interest rate of 15 percent per year until the claim is paid.

Appealing the Initial Determination If MetLife denies Your claim, You may appeal the denial. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision, or as soon as reasonably possible for situations in which You cannot reasonably meet the deadline. Appeals must be in writing and must include at least the following information:     

Name of Employee Name of the Plan Reference to the initial decision Whether the appeal is the first or second appeal of the initial determination An explanation why You are appealing the initial determination.

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

After MetLife receives Your written request, MetLife will conduct a full and fair review of Your claim.

Deference will not be given to initial denials, and MetLife’s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. Your appeal will be reviewed by a person holding the same professional license as the treating Dental provider. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim.

MetLife will notify You in writing of its final decision within 18 days after MetLife’s receipt of Your written request for review.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

Second Level Appeal If You disagree with the response to the initial appeal of the denied claim, You have the right to a second level appeal. We shall communicate Our final determination to You within 18 calendar days from receipt of the GCERT2000 notice/ak

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NOTICE FOR RESIDENTS OF ALASKA request, or as required by any applicable state or federal laws or regulations. Our communication to the You shall include the specific reasons for the determination.

External Appeal If You disagree with the response to the second appeal of the denied claim, You have the right to an external appeal. We will communicate the decision of the external appear agency in Writing. The decision will be made in accordance with the medical exigencies of the case involved, but in no event later than 21 working days after the appeal is filed, or, in the case of an expedited appeal, 72 hours after the time of requesting an external appeal of the health care insurer’s decision. Decisions made by an external appeal agency are binding on Us and You unless the aggrieved party files suit in superior court within 6 months from the decision of the external appeal agency. All costs of the external appeal process, except those incurred by You or the treating professional in support of the appeal, will be paid by Us.

Overpayments Recovery of Overpayments We have the right to recover any amount that is determined to be an overpayment, within 180 days from the date of service, whether for services received by You or Your Dependents.

An overpayment occurs if it is determined that: 

the total amount paid by Us on a claim for Dental Insurance benefits is more than the total of the benefits due to You under this certificate; or



payment We made should have been made by another group plan.

If such overpayment occurs, You have an obligation to reimburse Us. How We Recover Overpayments We may recover the overpayment, within 180 days from the date of service, from You by:   

stopping or reducing any future benefits payable for Dental Insurance; demanding an immediate refund of the overpayment from You; and taking legal action.

If the overpayment results from Our having made a payment to You that should have been made under another group plan, We may recover such overpayment within 180 days from the date of service, from one or more of the following:   

any other insurance company; any other organization; or any person to or for whom payment was made.

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NOTICE FOR RESIDENTS OF ARKANSAS If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact: Arkansas Insurance Department Consumer Services Division 1200 West Third Street Little Rock, Arkansas 72201 (501) 371-2640 or (800) 852-5494

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6 ASPEN 2018 BENEFITS :: 223

NOTICE FOR RESIDENTS OF CALIFORNIA IMPORTANT NOTICE TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE POLICYHOLDER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS YOU RECEIVE AFTER FILING A CLAIM. IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA INSURANCE DEPARTMENT AT: DEPARTMENT OF INSURANCE 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 1 (800) 927-4357

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NOTICE FOR RESIDENTS OF THE STATE OF CALIFORNIA California law provides that for dental insurance, domestic partners of California’s residents must be treated the same as spouses. If the certificate does not already have a definition of domestic partner, then the following definition applies: “Domestic Partner means each of two people, one of whom is an employee of the Employer, a resident of California and who have registered as domestic partners or members of a civil union with the California or another government recognized by California as having similar requirements.

For purposes of determining who may become a Covered Person, the term does not include any person who:  

is in the military of any country or subdivision of a country; is insured under the Group Policy as an employee.”

If the certificate already has a definition of domestic partner, that definition will apply to California residents, as long as it recognizes as a domestic partner any person registered as the employee’s domestic partner with the California government or another government recognized by California as having similar requirements.

Wherever the term Spouse appears, except in the definition of Spouse, it shall be replaced by Spouse or Domestic Partner.

Wherever the term step-child appears, it is replaced by step-child or child of Your Domestic Partner.

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8 ASPEN 2018 BENEFITS :: 225

NOTICE FOR RESIDENTS OF GEORGIA IMPORTANT NOTICE The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence.

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NOTICE FOR RESIDENTS OF IDAHO If You have a question concerning Your coverage or a claim, first contact the Employer. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Employer and MetLife, You should feel free to contact: Idaho Department of Insurance Consumer Affairs 700 West State Street, 3rd Floor PO Box 83720 Boise, Idaho 83720-0043 1-800-721-3272 or www.DOI.Idaho.gov

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NOTICE FOR RESIDENTS OF ILLINOIS IMPORTANT NOTICE To make a complaint to MetLife, You may write to: MetLife 200 Park Avenue New York, New York 10166 The address of the Illinois Department of Insurance is: Illinois Department of Insurance Public Services Division Springfield, Illinois 62767

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NOTICE FOR RESIDENTS OF INDIANA Questions regarding your policy or coverage should be directed to: Metropolitan Life Insurance Company 1-800-275-4638 If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204 Consumer Hotline: (800) 622-4461; (317) 232-2395 Complaint can be filed electronically at www.in.gov/idoi

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NOTICE FOR RESIDENTS OF MAINE You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a default on Your part, such as nonpayment of a contribution that is due. The intent is to allow reinstatements where the default is due to the insured personâ&#x20AC;&#x2122;s suffering from cognitive impairment or functional incapacity.

You may make this designation by completing a "Third-Party Notice Request Form" and sending it to MetLife.

Once You have made a designation, You may cancel or change it by filling out a new Third-Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date MetLife receives the form. Call MetLife at the toll-free telephone number shown on the face page of this certificate to obtain a Third-Party Notice Request Form. Within 90 days after cancellation of coverage for nonpayment of premium, You, any person authorized to act on Your behalf, or any covered Dependent may request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional incapacity at the time of cancellation.

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NOTICE FOR MASSACHUSETTS RESIDENTS The following provisions are required by Massachusetts law.

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14

ASPEN 2018 BENEFITS :: 231

NOTICE FOR MASSACHUSETTS RESIDENTS (Continued) The following provisions are required by Massachusetts law.

Summary of Utilization Review Procedures MetLife reviews claims for evidence of need for certain dental procedures. These reviews are conducted by licensed dentists. If there is no evidence of need MetLife will deny benefits for a claim. MetLife also reviews claims to determine whether there exists a less costly treatment for a dental condition that is generally considered effective to treat the condition. If a less costly alternative treatment exists, MetLife will determine benefits based on the alternative treatment. If you want to determine the status of any such claim review, you can call MetLife at 1-800-275-4638.

Summary of Quality Assurance Programs MetLife performs a check on certain credentials of any dentist applying to participate in MetLifeâ&#x20AC;&#x2122;s Participating Dentist Program (PDP). If the credentials do not meet MetLifeâ&#x20AC;&#x2122;s standards, for example if a dentist does not have a valid license, the dentist will not be permitted to participate in the PDP. MetLife does not interfere with the traditional relationship between PDP dentists and their patients, or any determination between the patient and dentist as to what the appropriate dental treatment may be. MetLife dental plans also allow you to choose between any dentist, whether they participate in the PDP or not. Therefore you should choose your dentist carefully, and you are responsible to be sure that your dentist delivers quality dental care.

Involuntary Disenrollment Rate The involuntary disenrollment rate among insureds of MetLife is 0.

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15 2018 BENEFITS :: 232 ASPEN

NOTICE FOR RESIDENTS OF MASSACHUSETTS CONTINUATION OF DENTAL INSURANCE 1. If Your Dental Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be continued for 90 days after the date it ends.

2. If Your Dental Insurance ends because:  

You cease to be in an Eligible Class; or Your employment terminates;

for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days after the date it ends.

Continuation of Your Dental Insurance under the CONTINUATION WITH PREMIUM PAYMENT subsection will end before the end of continuation periods shown above if You become covered for similar benefits under another plan.

Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws, Chapter 151A, Section 71A. CONTINUATION OF DENTAL INSURANCE FOR YOUR FORMER SPOUSE If the judgment of divorce dissolving Your marriage provides for continuation of insurance for Your former Spouse when You remarry, Dental Insurance for Your former Spouse that would otherwise end may be continued.

To continue Dental insurance under this provision: 1. You must make a written request to the employer to continue such insurance; 2. You must make any required premium to the employer for the cost of such insurance.

The request form will be furnished by the Employer.

Such insurance may be continued from the date Your marriage is dissolved until the earliest of the following: 

the date Your former Spouse remarries;



the date of expiration of the period of time specified in the divorce judgment during which You are required to provide Dental Insurance for Your former Spouse;



the date coverage is provided under any other group health plan;



the date Your former Spouse becomes entitled to Medicare;



the date Dental Insurance under the policy ends for all active employees, or for the class of active employees to which You belonged before Your employment terminated;



the date of expiration of the last period for which the required premium payment was made; or



the date such insurance would otherwise terminate under the policy.

If Your former Spouse is eligible to continue Dental Insurance under this provision and any other provision of this Policy, all such continuation periods will be deemed to run concurrently with each other and shall not be deemed to run consecutively.

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NOTICE FOR NEW HAMPSHIRE RESIDENTS CONTINUATION OF YOUR DENTAL INSURANCE If You are a resident of New Hampshire, Your Dental Insurance may be continued if it ends because Your employment ends unless: 

Your employment ends due to Your gross misconduct;



this Dental Insurance ends for all employees;



this Dental Insurance is changed to end Dental Insurance for the class of employees to which You belong;



You are entitled to enroll in Medicare; or



Your Dental Insurance ends because You failed to pay the required premium.

The Employer must give You written notice of: 

Your right to continue Your Dental Insurance;



the amount of premium payment that is required to continue Your Dental Insurance;



the manner in which You must request to continue Your Dental Insurance and pay premiums; and



the date by which premium payments will be due.

The premium that You must pay for Your continued Dental Insurance may include: 

any amount that You contributed for Your Dental Insurance before it ended;



any amount the Employer paid; and



an administrative charge which will not to exceed two percent of the rest of the premium.

To continue Your Dental Insurance, You must: 

send a written request to continue Your Dental Insurance; and



pay the first premium within 30 days after the date Your employment ends.

The maximum continuation period will be the longest of: 

36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;



29 months if You become entitled to disability benefits under Social Security within 60 days of the date Your Employment ends; or 18 months.



Your continued Dental Insurance will end on the earliest of the following to occur: 

the end of the maximum continuation period;



the date this Dental Insurance ends;



the date this Dental Insurance is changed to end Dental Insurance for the class of employees to which You belong;



the date You are entitled to enroll for Medicare;



if You do not pay the required premium to continue Your Dental Insurance; or



the date You become eligible for coverage under any other group dental coverage.

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NOTICE FOR NEW HAMPSHIRE RESIDENTS (Continued) CONTINUATION OF YOUR DEPENDENT’S DENTAL INSURANCE If You are a resident of New Hampshire, Your Dental Insurance for Your Dependents may be continued if it ends because Your employment ends, Your marriage ends in divorce or separation, or You die, unless: 

Your employment ends due to Your gross misconduct;



this Dental Insurance ends for all Dependents;



this Dental Insurance is changed, for the class of employees to which You belong, to end Dental Insurance for Dependents;



the Dependent is entitled to enroll in Medicare; or



Your Dental Insurance for Your Dependents ends because You fail to pay a required premium.

If Dental Insurance for Your Dependents ends because Your marriage ends in divorce or separation, the party responsible under the divorce decree or separation agreement for payment of premium for continued Dental Insurance must notify the employer, in writing, within 30 days of the date of the divorce decree or separation agreement that the divorce or separation has occurred. If You and Your divorced or separated Spouse share responsibility for payment of the premium for continued Dental Insurance, both You and Your divorced or separated Spouse must provide the notification.

The Employer must give You, or Your former Spouse if You have died or Your marriage has ended, written notice of: 

Your right to continue Your Dental Insurance for Your Dependents;



the amount of premium payment that is required to continue Your Dental Insurance for Your Dependents;



the manner in which You or Your former Spouse must request to continue Your Dental Insurance for Your Dependents and pay premiums; and



the date by which premium payments will be due.

The premium that You or Your former Spouse must pay for continued Dental Insurance for Your Dependents may include: 

any amount that You contributed for Your Dental Insurance before it ended; and



any amount the Employer paid.

To continue Dental Insurance for Your Dependents, You or Your former Spouse must: 

send a written request to continue Dental Insurance for Your Dependents; and



must pay the first premium within 30 days of the date Dental Insurance for Your Dependents ends.

If You, and Your former Spouse, if applicable, fail to provide any required notification, or fail to request to continue Dental Insurance for Your Dependents and pay the first premium within the time limits stated in this section, Your right to continue Dental Insurance for Your Dependents will end.

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NOTICE FOR NEW HAMPSHIRE RESIDENTS (Continued) CONTINUATION OF YOUR DEPENDENT’S DENTAL INSURANCE (Continued) The maximum continuation period will be the longest of the following that applies: 

36 months if Dental Insurance for Your Dependents ends because Your marriage ends in divorce or separation, except that with respect to a Spouse who is age 55 or older when your marriage ends in divorce or separation the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group plan;



36 months if Dental Insurance for Your Dependents ends because You die, except that with respect to a Spouse who is age 55 or older when You die, the maximum continuation period will end when Your surviving Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;



36 months if Dental Insurance for Your Dependents ends because You become entitled to benefits under Title XVIII of Social Security, except that with respect to a Spouse who is age 55 or older when You become entitled to benefits under Title XVIII of Social Security, the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;



36 months if You become entitled to benefits under Title XVIII of Social Security while You are already receiving continued benefits under this section, except that with respect to a Spouse who is age 55 or older when You first become entitled to continue Your Dental Insurance the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group dental coverage;



36 months with respect to a Dependent Child if Dental Insurance ends because the Child ceases to be a Dependent Child;



36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;



29 months if Dental Insurance for Your Dependents ends because Your employment ends, and within 60 days of the date Your employment ends you become entitled to disability benefits under Social Security; or



18 months if Dental Insurance for Your Dependents ends because Your employment ends.

A Dependent's continued Dental Insurance will end on the earliest of the following to occur: 

the end of the maximum continuation period;



the date this Dental Insurance ends;



the date this Dental Insurance is changed to end Dental Insurance for Dependents for the class of employees to which You belong;



the date the Dependent becomes entitled to enroll for Medicare;



if You do not pay a required premium to continue Dental Insurance for Your Dependents; or



the date the Dependent becomes eligible for coverage under any other group dental coverage.

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NOTICE FOR RESIDENTS OF NORTH CAROLINA UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER, PRINCIPAL, AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE PAYMENT OF GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS, SHALL: (1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE INSURANCE, HOSPITAL, MEDICAL, OR DENTAL SERVICE CORPORATION PLAN, MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN COVERAGES AND THE CONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSONS INSURED, BY WILLFULLY FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE WITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT, AND (2) WILLFULLY FAIL TO DELIVER, AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE COVERAGES, TO ALL PERSONS COVERED BY THE GROUP POLICY A WRITTEN NOTICE OF THE PERSON'S INTENTION TO STOP PAYMENT OF PREMIUMS. THIS WRITTEN NOTICE MUST ALSO CONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP POLICY OF THEIR RIGHTS TO HEALTH INSURANCE CONVERSION POLICIES UNDER ARTICLE 53 OF CHAPTER 58 OF THE GENERAL STATUTES AND THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THE FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE 68 OF CHAPTER 58 OF THE GENERAL STATUTES. VIOLATION OF THIS LAW IS A FELONY. ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECT TO A COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOR EXPENSES OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE.

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NOTICE FOR RESIDENTS OF PENNSYLVANIA Dental Insurance for a Dependent Child may be continued past the age limit if that Child is a fulltime student and insurance ends due to the Child being ordered to active duty (other than active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the United States.

Insurance will continue if such Child:    

re-enrolls as a full-time student at an accredited school, college or university that is licensed in the jurisdiction where it is located; re-enrolls for the first term or semester, beginning 60 or more days from the child’s release from active duty; continues to qualify as a Child, except for the age limit; and submits the required Proof of the child’s active duty in the National Guard or a Reserve Component of the United States Armed Forces.

Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of the date:  

the insurance has been continued for a period of time equal to the duration of the child’s service on active duty; or the child is no longer a full-time student.

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NOTICE FOR RESIDENTS OF ALL STATES THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.

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22 ASPEN 2018 BENEFITS :: 239

NOTICE FOR RESIDENTS OF UTAH Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Utah law, which determines who and what is covered and the amounts of coverage.

The Association was established to provide protection in the unlikely event that your life, health, or annuity insurance company becomes financially unable to meet its obligations and is taken over by its insurance regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other insurance companies.

The basic protections provided by the Association are:  Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values  Health Insurance o $500,000 in hospital, medical and surgical insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in disability income insurance benefits o $500,000 in other types of health insurance benefits  Annuities o $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits.

Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a complete description of coverage, consult Utah Code, Title 3 lA, Chapter 28.

Insurance companies and agents are prohibited by Utah law to use the existence of the Association or its coverage to encourage you to purchase insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between Utah law and this notice, Utah law will control.

To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.utlifega.org or contact: Utah Life and Health Insurance Guaranty Assoc.

60 East South Temple, Suite 500 Salt Lake City UT 84111 (801) 320-9955

Utah Insurance Department 3110 State Office Building Salt Lake City UT 84114-6901 (801) 538-3800

A written complaint about misuse of this Notice or the improper use of the existence of the Association may be filed with the Utah Insurance Department at the above address.

GTY-NOTICE-UT-0710

23 ASPEN 2018 BENEFITS :: 240

NOTICE FOR RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have additional questions You may contact the insurance company issuing this insurance at the following address and telephone number: MetLife 200 Park Avenue New York, New York 10166 Attn: Corporate Consumer Relations Department To phone in a claim related question, You may call Claims Customer Service at: 1-800-275-4638 If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the Virginia State Corporation Commissionâ&#x20AC;&#x2122;s Bureau of Insurance at: The Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA 23209 1-877-310-6560 - toll-free 1-804-371-9032 - locally www.scc.virginia.gov - web address ombudsman@scc.virginia.gov - email Or: The Virginia Department of Health (The Center for Quality Health Care Services and Consumer Protection) 3600 West Broad St Suite 216 Richmond, VA 23230 1-800-955-1819 Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your agent, company or the Bureau of Insurance, have Your policy number available.

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NOTICE FOR RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE If You have any questions regarding an appeal or grievance concerning the dental services that You have been provided that have not been satisfactorily addressed by this Dental Insurance, You may contact the Virginia Office of the Managed Care Ombudsman for assistance.

You may contact the Virginia Office of the Managed Care Ombudsman either by dialing toll free at (877) 3106560, or locally at (804) 371-9032, via the internet at Web address www.scc.virginia.gov, email at ombudsman@scc.virginia.gov, or mail to: The Office of the Managed Care Ombudsman Bureau of Insurance, P.O. Box 1157 Richmond, VA 23218

GCERT2000 notice/va1

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NOTICE FOR RESIDENTS OF WISCONSIN

KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? - If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.

MetLife Attn: Corporate Consumer Relations Department 200 Park Avenue New York, NY 10166-0188 1-800-638-5433

You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsinâ&#x20AC;&#x2122;s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting:

Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1-800-236-8517 outside of Madison or 608-266-0103 in Madison.

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26 ASPEN 2018 BENEFITS :: 243

NOTICE FOR RESIDENTS OF LOUISIANA, MINNESOTA, MONTANA, NEW MEXICO, UTAH AND WASHINGTON The Definition of Child In The Definitions Section Of This Certificate Is Modified For The Coverage Listed Below: For Louisiana Residents (Dental Insurance): The term also includes Your grandchildren residing with You. The age limit for children and grandchildren will not be less than 26, regardless of the child’s or grandchild’s marital status, student status or full-time employment status. Your natural child, adopted child, stepchild or grandchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. In addition, marital status will not prevent or cease the continuation of insurance for a mentally or physically handicapped child or grandchild past the age limit.

For Minnesota Residents (Dental Insurance): The term also includes Your grandchildren who are financially dependent upon You and reside with You continuously from birth. The age limit for children and grandchildren will not be less than 25 regardless of the child’s or grandchild’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a Child under this insurance.

For Montana Residents (Dental Insurance): The term also includes newborn infants of any person insured under this certificate. The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a child under this insurance.

For New Mexico Residents (Dental Insurance): The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild will not be denied dental insurance coverage under this certificate because:   

that child was born out of wedlock; that child is not claimed as Your dependent on Your federal income tax return; or that child does not reside with You.

For Utah Residents (Dental Insurance): The age limit for children will not be less than 26, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported

by You to qualify as a Child under this insurance.

For Washington Residents Dental Insurance: The age limit for children will not be less than 26, regardless of the child’s marital status, student status, or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance.

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NOTICE FOR RESIDENTS OF ALL STATES WHO ARE INSURED FOR DENTAL INSURANCE Notice Regarding Your Rights and Responsibilities Rights: 

We will treat communications, financial records and records pertaining to your care in accordance with all applicable laws relating to privacy.



Decisions with respect to dental treatment are the responsibility of You and the dentist. We neither require nor prohibit any specified treatment. However, only certain specified services are covered for benefits. Please see the Dental Insurance sections of this certificate for more details.



You may request a pre-treatment estimate of benefits for the dental services to be provided. However, actual benefits will be determined after treatment has been performed.



You may request a written response from MetLife to any written concern or complaint.



You have the right to receive an explanation of benefits which describes the benefit determinations for your dental insurance.

Responsibilities: 

You are responsible for the prompt payment of any charges for services performed by the dentist. If the dentist agrees to accept part of the payment directly from MetLife, you are responsible for prompt payment of the remaining part of the dentist’s charge.



You should consult with the dentist about treatment options, proposed and potential procedures, anticipated outcomes, potential risks, anticipated benefits and alternatives. You should share with the dentist the most current, complete and accurate information about your medical and dental history and current conditions and medications.



You should follow the treatment plans and health care recommendations agreed upon by You and the dentist.

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TABLE OF CONTENTS The bottom left of each page of this certificate has a unique coding which describes the section of the certificate that the page contains (fp = Certificate Face Page, sch = Schedule of Benefits).

Section Page CERTIFICATE FACE PAGE ............................................................................................................................... 1 NOTICES ............................................................................................................................................................ 2 TABLE OF CONTENTS .................................................................................................................................... 29 SCHEDULE OF BENEFITS .............................................................................................................................. 30 DEFINITIONS ................................................................................................................................................... 31 ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ...................................................................................... 35 Eligible Classes ............................................................................................................................................. 35 Date You Are Eligible For Insurance ............................................................................................................. 35 Enrollment Process For Dental Insurance..................................................................................................... 35 Date Your Insurance Takes Effect ................................................................................................................ 35 Date Your Insurance Ends ............................................................................................................................ 36 ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS ......................................................... 37 Eligible Classes For Dependent Insurance ................................................................................................... 37 Date You Are Eligible For Dependent Insurance .......................................................................................... 37 Enrollment Process For Dependent Dental Insurance .................................................................................. 37 Date Your Insurance Takes Effect For Your Dependents................................................................................ 37 Date Your Insurance For Your Dependents Ends ......................................................................................... 38 DENTAL INSURANCE: SPECIAL RULES FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP DENTAL COVERAGE ........................................................................................................................ 40 CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.................................................................... 41 For Mentally or Physically Handicapped Children ......................................................................................... 41 For Family And Medical Leave ...................................................................................................................... 41 COBRA Continuation For Dental Insurance .................................................................................................. 41 At The Employer's Option.............................................................................................................................. 41 EVIDENCE OF INSURABILITY ........................................................................................................................ 43 DENTAL INSURANCE ...................................................................................................................................... 44 DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES ............................................................... 47 Type A Covered Services .............................................................................................................................. 47 Type B Covered Services .............................................................................................................................. 47 Type C Covered Services.............................................................................................................................. 49 Type D Covered Services.............................................................................................................................. 50 DENTAL INSURANCE: EXCLUSIONS ............................................................................................................ 51 DENTAL INSURANCE: COORDINATION OF BENEFITS ............................................................................... 53 FILING A CLAIM ............................................................................................................................................... 58 DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS .................................................................... 59 GENERAL PROVISIONS.................................................................................................................................. 61 Assignment .................................................................................................................................................... 61 Dental Insurance: Who We Will Pay ............................................................................................................. 61 Entire Contract............................................................................................................................................... 61 Incontestability: Statements Made By You .................................................................................................... 61 Misstatement of Age ...................................................................................................................................... 61 Conformity With Law ..................................................................................................................................... 61 Autopsy .......................................................................................................................................................... 61 Overpayments ............................................................................................................................................... 61

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SCHEDULE OF BENEFITS This schedule shows the benefits that are available under the Group Policy. You and Your Dependents will only be insured for the benefits:   

for which You and Your Dependents become and remain eligible, and which You elect, if subject to election; and which are in effect.

BENEFIT

BENEFIT AMOUNT AND HIGHLIGHTS

Dental Insurance For You and Your Dependents For All Active Full-Time Employees who elect the High Option Dental Plan

Covered Percentage for:

In-Network based on the Maximum Allowed Charge

Out-of-Network based on the Reasonable and Customary Charge

Type A Services

100%

100%

Type B Services

80%

80%

Type C Services

50%

50%

Type D Services (Orthodontic)

50%

50%

Deductibles for:

In-Network

Out-of-Network

Yearly Individual Deductible

$50 for the following Covered Services Combined: Type B & Type C

$50 for the following Covered Services Combined: Type B & Type C

Yearly Family Deductible

$150 for the following Covered Services Combined: Type B & Type C

$150 for the following Covered Services Combined: Type B & Type C

Maximum Benefit:

In-Network

Out-of-Network

Yearly Individual Maximum

$1,750 for the following Covered Services: Type A, Type B & Type C $1,500

$1,750 for the following Covered Services: Type A, Type B & Type C $1,500

Lifetime Individual Maximum for Type D Covered Services (Orthodontic)

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DEFINITIONS As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning.

Actively at Work or Active Work means that You are performing all of the usual and customary duties of Your job on a Full-Time basis. This must be done at:   

the Employer's place of business; an alternate place approved by the Employer; or a location to which the Employer's business requires You to travel.

You will be deemed to be Actively at Work during weekends or Employer-approved vacations, holidays or business closures if You were Actively at Work on the last scheduled work day preceding such time off.

Cast Restoration means an inlay, onlay, or crown.

Child means the following: (for residents of Louisiana, Minnesota, Montana, New Mexico, Utah and Washington, the Child Definition is modified as explained in the Notice pages of this certificate - please consult the Notice) For Dental Insurance, Your natural or adopted child; Your stepchild (including the child of a Domestic Partner); or a child who resides with and is fully supported by You; and who, in each case, is under age 26.

The term also includes Your grandchild who is under age 26, and who was able to be claimed by You as a Dependent for Federal Income Tax purposes at the time You applied for Dental Insurance.

A child will be considered Your adopted child during the period You are party to a suit in which You are seeking the adoption of the child.

If You provide Us notice, a Child also includes a child for whom You must provide Dental Insurance due to a Qualified Medical Child Support Order as defined in the United States Employee Retirement Income Security Act of 1974 as amended.

The term does not include any person who:  

is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or is insured under the Group Policy as an employee.

Contributory Insurance means insurance for which the Employer requires You to pay any part of the premium.

Contributory Insurance includes: Personal and Dependent Dental Insurance.

Covered Percentage means:  

for a Covered Service performed by an In-Network Dentist, the percentage of the Maximum Allowed Charge that We will pay for such services after any required Deductible is satisfied; and for a Covered Service performed by an Out-of-Network Dentist, the percentage of the Reasonable and Customary Charge that We will pay for such services after any required Deductible is satisfied.

Covered Service means a dental service used to treat Your or Your Dependent’s dental condition which is:   

prescribed or performed by a Dentist while such person is insured for Dental Insurance; Dentally Necessary to treat the condition; and described in the SCHEDULE OF BENEFITS or DENTAL INSURANCE sections of this certificate.

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DEFINITIONS Deductible means the amount You or Your Dependents must pay before We will pay for Covered Services.

Dental Hygienist means a person trained to:  

remove calcareous deposits and stains from the surfaces of teeth; and provide information on the prevention of oral disease.

Dentally Necessary means that a dental service or treatment is performed in accordance with generally accepted dental standards as determined by Us and is:  

necessary to treat decay, disease or injury of the teeth; or essential for the care of the teeth and supporting tissues of the teeth.

Dentist means:  

a person licensed to practice dentistry in the jurisdiction where such services are performed; or any other person whose services, according to applicable law, must be treated as Dentist’s services for purposes of the Group Policy. Each such person must be licensed in the jurisdiction where the services are performed and must act within the scope of that license. The person must also be certified and/or registered if required by such jurisdiction.

Dentures means fixed partial dentures (bridgework), removable partial dentures and removable full dentures.

Dependent(s) means Your Spouse and/or Child.

Domestic Partner means each of two people, one of whom is an employee of the Employer, who: 

have registered as each other's domestic partner, civil union partner or reciprocal beneficiary with a government agency where such registration is available; or



are of the same or opposite sex and have a mutually dependent relationship so that each has an insurable interest in the life of the other. Each person must be: 1.

2.

3.

4.

5.

18 years of age or older; unmarried; the sole domestic partner of the other; sharing a primary residence with the other; and not related to the other in a manner that would bar their marriage in the jurisdiction in which they reside.

A Domestic Partner declaration attesting to the existence of an insurable interest in one another's lives must be completed and Signed by the employee.

Full-Time means Active Work on the Employer's regular work schedule for the class of employees to which You belong. The work schedule must be at least 30 hours a week. Full-Time does not include temporary or seasonal employees.

In-Network Dentist means a Dentist who participates in the Preferred Dentist Program and has a contractual agreement with Us to accept the Maximum Allowed Charge as payment in full for a dental service.

Maximum Allowed Charge means the lesser of:  

the amount charged by the Dentist; or the maximum amount which the In-Network Dentist has agreed with Us to accept as payment in full for the dental service.

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DEFINITIONS Noncontributory Insurance means insurance for which the Employer does not require You to pay any part of the premium.

Out-of-Network Dentist means a Dentist who does not participate in the Preferred Dentist Program.

Physician means:  

a person licensed to practice medicine in the jurisdiction where such services are performed; or any other person whose services, according to applicable law, must be treated as Physician’s services for purposes of the Group Policy. Each such person must be licensed in the jurisdiction where the service is performed and must act within the scope of that license. Such person must also be certified and/or registered if required by such jurisdiction.

Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish:   

the nature and extent of the loss or condition; Our obligation to pay the claim; and the claimant’s right to receive payment.

Proof must be provided at the claimant’s expense.

Reasonable and Customary Charge is the lowest of: 

the Dentist’s actual charge for the services or supplies (or, if the provider of the service or supplies is not a Dentist, such other provider’s actual charge for the services or supplies) (the 'Actual Charge'); or



the usual charge by the Dentist or other provider of the services or supplies for the same or similar services or supplies (the 'Usual Charge'); or



the usual charge of other Dentists or other providers in the same geographic area equal to the 90th percentile of charges as determined by MetLife based on charge information for the same or similar services or supplies maintained in MetLife’s Reasonable and Customary Charge records (the ‘Customary Charge’). Where MetLife determines that there is inadequate charge information maintained in MetLife’s Reasonable and Customary Charge records for the geographic area in question, the Customary Charge will be determined based on actuarially sound principles.

An example of how the 90th percentile is calculated is to assume one hundred (100) charges for the same service are contained in MetLife’s Reasonable and Customary charge records. These 100 hundred (100) charges would be sorted from lowest to highest charged amount and numbered 1 through 100. The 90th percentile of charges is the charge that is equal to the charge numbered 90.

Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

Spouse means Your lawful Spouse. The term also includes Your Domestic Partner.

The term does not include any person who:  

is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or is insured under the Group Policy as an employee.

We, Us and Our mean MetLife.

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DEFINITIONS Written or Writing means a record which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

Year or Yearly means the 12 month period that begins January 1.

You and Your mean an employee who is insured under the Group Policy for the insurance described in this certificate.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ELIGIBLE CLASS(ES) All Active Full-Time Employees who elect the High Option Dental Plan

DATE YOU ARE ELIGIBLE FOR INSURANCE You may only become eligible for the insurance available for Your class as shown in the SCHEDULE OF BENEFITS. For All Active Full-Time Employees who elect the High Option Dental Plan You will be eligible for insurance on the later of: 1. January 01, 2017; and 2. the first day of the month coincident with or next following the date You enter that class.

Waiting Period means the period of continuous membership in an eligible class that You must wait before You become eligible for insurance. This period begins on the date You enter an eligible class and ends on the date You complete the period(s) specified.

ENROLLMENT PROCESS FOR DENTAL INSURANCE If You are eligible for insurance, You may enroll for such insurance by completing the required form in Writing.

If You enroll for Contributory Insurance, You must also give the Employer Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Employer how much You will be required to contribute.

The Dental Insurance has a regular enrollment period established by the Employer. Subject to the rules of the Group Policy, You may enroll for Dental Insurance only when You are first eligible or during an annual enrollment period or If You have a Qualifying Event. You should contact the Employer for more information regarding the annual enrollment period.

DATE YOUR INSURANCE TAKES EFFECT Enrollment When First Eligible If You complete the enrollment process within 31 days of becoming eligible for insurance you are a timely entrant, such insurance will take effect on the date You become eligible, provided You are Actively at Work on that date.

If You are not Actively at Work on the date the insurance would otherwise take effect, the benefit will take effect on the day You resume Active Work.

Enrollment During First Annual Enrollment Period Following the Date You Became Eligible You will be able to enroll for insurance during the first annual enrollment period. When You complete the enrollment process during the first annual enrollment period, such insurance will take effect on the first day of the month coincident with or next following the enrollment period, if You are actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (CONTINUED) Enrollment During Any Subsequent Dental Enrollment Period During any subsequent annual enrollment period for dental insurance as determined by the Employer, You may enroll for insurance for which You are eligible or choose a different option than the one for which You are currently enrolled. If You are not currently enrolled for Dental Insurance but You enroll or make changes to Your insurance during a subsequent enrollment period, the Dental Insurance takes effect on the first day of the month following the enrollment period, if You are Actively at Work on that day.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment Due to a Qualifying Event You may enroll for insurance for which You are eligible or change the amount of Your insurance between annual enrollment periods only if You have a Qualifying Event.

If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or changes to Your insurance made as a result of a Qualifying Event will take effect on the date of the Qualifying Event, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Qualifying Event includes: 

marriage; or



the birth, adoption or placement for adoption of a dependent child; or



divorce, legal separation or annulment; or



the death of a dependent; or



You previously did not enroll for dental coverage for You or Your dependent because You had other group coverage, but that coverage has ceased due to loss of eligibility for the other group coverage; or



Your dependent's ceasing to qualify as a dependent under this insurance or under other group coverage.

DATE YOUR INSURANCE ENDS Your insurance will end on the earliest of: 1. the date the Group Policy ends; 2. the date insurance ends for Your class; 3. the end of the period for which the last premium has been paid for You; 4. the last day of the calendar month in which Your employment ends; Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; or 5. the last day of the calendar month in which You retire in accordance with the Employer’s retirement plan.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS ELIGIBLE CLASS(ES) FOR DEPENDENT INSURANCE All Active Full-Time Employees who elect the High Option Dental Plan

DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE You may only become eligible for the Dependent insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. For All Active Full-Time Employees who elect the High Option Dental Plan

You will be eligible for Dependent insurance on the later of: 1. January 01, 2017; and 2. the first day of the month coincident with or next following the date You enter that class.

Waiting Period means the period of continuous membership in an eligible class that You must wait before You become eligible for Dependent insurance. This period begins on the date You enter an eligible class and ends on the date You complete the period(s) specified.

No person may be insured as a Dependent of more than one employee.

ENROLLMENT PROCESS FOR DEPENDENT DENTAL INSURANCE If You are eligible for Dependent Insurance, You may enroll for such insurance by completing the required form in Writing for each Dependent to be insured. If You enroll for Contributory Insurance, You must also give the Employer Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Employer how much You will be required to contribute.

In order to enroll for Dental Insurance for Your Dependents, You must either (a) already be enrolled for Dental Insurance for You or (b) enroll at the same time for Dental Insurance for You. The Dental Insurance has a regular enrollment period established by the Employer. Subject to the rules of the Group Policy, You may enroll for Dependent Dental Insurance only when You are first eligible or during an annual enrollment period or If You have a Qualifying Event. You should contact the Employer for more information regarding the annual enrollment period.

DATE YOUR INSURANCE TAKES EFFECT FOR YOUR DEPENDENTS Enrollment When First Eligible If You complete the enrollment process for Dependent Dental Insurance within 31 days of becoming eligible for Dependent Insurance you are a timely entrant, such insurance will take effect on the later of:  

the date You become eligible for such insurance; and the date You enroll

provided You are Actively at Work on that date. If You are not Actively at Work on that date, it will take effect on the day You return to Active Work.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (CONTINUED) Enrollment During First Annual Enrollment Period Following the Date You Became Eligible You will be able to enroll for Dependent Insurance during the first annual enrollment period. When You complete the enrollment process during the first annual enrollment period, such insurance will take effect on the first day of the month coincident with or next following the enrollment period, if You are actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment During Any Subsequent Dental Enrollment Period During any subsequent annual enrollment period for dental insurance as determined by the Employer, You may enroll for insurance for which You are eligible or choose a different option than the one for which You are currently enrolled. If You are not currently enrolled for Dependent Dental Insurance but You enroll or make changes to Your insurance during a subsequent enrollment period, the Dependent Dental Insurance takes effect on the first day of the month following the enrollment period, if You are Actively at Work on that day.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment Due to a Qualifying Event You may enroll for Dependent Insurance for which You are eligible or change the amount of Your Dependent Insurance between annual enrollment periods only if You have a Qualifying Event.

If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or changes to Your insurance made as a result of a Qualifying Event will take effect on the date of the Qualifying Event, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Qualifying Event includes:      

marriage; or the birth, adoption or placement for adoption of a dependent child; or divorce, legal separation or annulment; or the death of a dependent; or You previously did not enroll for dental coverage for You or Your dependent because You had other group coverage, but that coverage has ceased due to loss of eligibility for the other group coverage; or Your dependent's ceasing to qualify as a dependent under this insurance or under other group coverage.

DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS A Dependent's insurance will end on the earliest of: 1. the date Your Dental Insurance ends; 2. the date You die; 3. the date the Group Policy ends; 4. the date Insurance for Your Dependents ends under the Group Policy; 5. the date Insurance for Your Dependents ends for Your class; 6. the last day of the calendar month in which Your employment ends; Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT. GCERT2000 e/dep 38 ASPEN 2018 BENEFITS :: 255

ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (CONTINUED) 7. the end of the period for which the last premium has been paid; 8. the date the person ceases to be a Dependent except in the case of a Dependent Child who has reached the maximum age as defined in the DEFINITIONS section, Insurance will end on the last day of the calendar month; 9. for Utah residents, the last day of the calendar month the person ceases to be a Dependent; 10. the last day of the calendar month in which You retire in accordance with the Employer's retirement plan.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.

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SPECIAL RULES FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP DENTAL COVERAGE The following rules will apply if this Dental Insurance replaces other group dental coverage provided to You by the Employer.

Prior Plan means the group dental coverage provided to You by the Employer on the day before the Replacement Date.

Replacement Date means the effective date of this Dental Insurance under the Group Policy.

Rules if You and Your Dependents were Covered Under the Prior Plan on the Day Before the Replacement Date: 1. if You and Your Dependents were covered under the Prior Plan on the day before the Replacement Date, You will be eligible for this Dental Insurance on the Replacement Date if You are in an eligible class on such date; 2. if any of the following conditions occurred while coverage was in effect under the Prior Plan, We will treat such conditions as though they occurred while this Dental Insurance is in effect: 

the loss of a tooth; and



the accumulation of amounts toward: 

Annual Deductibles;



Annual Maximum Benefits;



Lifetime Maximum Benefits;

3. if a dental service was received while the Prior Plan was in effect and such service would be a Covered Service subject to frequency and/or time limitations if performed while this Dental Insurance is in effect, the receipt of such prior service will be counted toward the time and frequency limitations under this Dental Insurance; 4. if a government mandated continuation of coverage under the Prior Plan was in effect on the Replacement Date, such coverage may be continued under this Dental Insurance if the required payment is made for the cost of such coverage. In such case, benefits will be available under this Dental Insurance until the earlier of: 

the date the continued coverage ends as set forth in the provisions of the government-mandated requirements; or



the date this Dental Insurance ends.

Rules if You and Your Dependents were NOT covered under the Prior Plan on the Day Before the Replacement Date: 1. You will be eligible for this Dental Insurance when You meet the eligibility requirements for such insurance as described in ELIGIBILITY PROVISIONS: INSURANCE FOR YOU; 2. Your Dependents will be eligible for this Dental Insurance when they meet the eligibility requirements for such insurance as described in ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS; and 3. We will credit any time accumulated toward any eligibility waiting period under the Prior Plan to the satisfaction of any eligibility waiting period required to be met under this Dental Insurance.

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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN Insurance for a Dependent Child may be continued past the age limit if the child is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of such handicap must be sent to Us within 31 days after the date the Child attains the age limit and at reasonable intervals after such date, but not more frequently than once a year after the two-year period following the child’s attainment of the limiting age.

Subject to the DATE INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue while such Child: 

remains incapable of self-sustaining employment because of a mental or physical handicap; and



continues to qualify as a Child, except for the age limit.

FOR FAMILY AND MEDICAL LEAVE Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave Act of 1993 (FMLA), or other legally mandated leave of absence or similar laws. Please contact the Employer for information regarding such legally mandated leave of absence laws.

COBRA CONTINUATION FOR DENTAL INSURANCE The following applies to employers with 20 or more employees that are not church or government plans: If Dental Insurance for You or a Dependent ends, You or Your Dependent may qualify for continuation of such insurance under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA).

Please refer to the COBRA section of Your summary plan description or contact the Employer for information regarding continuation of insurance under COBRA. AT THE EMPLOYER’S OPTION The Employer has elected to continue insurance by paying premiums for employees who cease Active Work in an eligible class for any of the reasons specified below. If Your insurance is continued, insurance for Your Dependents may also be continued. You will be notified by the Employer how much You will be required to contribute.

Insurance will continue for the following periods: 1. for the period You cease Active Work in an eligible class due to layoff up to 2 months.

2. for the period You cease Active Work in an eligible class due to injury or sickness up to 9 months.

3. for the period You cease Active Work in an eligible class due to any other Employer approved leave of absence up to 2 months.

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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (CONTINUED) At the end of any of the continuation periods listed above, Your insurance will be affected as follows: 

if You resume Active Work in an eligible class at this time, You will continue to be insured under the Group Policy;



if You do not resume Active Work in an eligible class at this time, Your employment will be considered to end and Your insurance will end in accordance with the DATE YOUR INSURANCE ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU.

If Your insurance ends, Your Dependents’ insurance will also end in accordance with the DATE INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS.

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EVIDENCE OF INSURABILITY No evidence of insurability is required for the insurance described in this certificate.

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DENTAL INSURANCE If You or a Dependent incur a charge for a Covered Service, Proof of such service must be sent to Us. When We receive such Proof, We will review the claim and if We approve it, will pay the insurance in effect on the date that service was completed.

This Dental Insurance gives You access to Dentists through the MetLife Preferred Dentist Program (PDP).

Dentists participating in the PDP have agreed to limit their charge for a dental service to the Maximum Allowed Charge for such service. Under the PDP, We pay benefits for Covered Services performed by either In-Network Dentists or Out-of-Network Dentists. However, You may be able to reduce Your out-of-pocket costs by using an In-Network Dentist because Out-of-Network Dentists have not entered into an agreement with Us to limit their charges. You are always free to receive services from any Dentist. You do not need any authorization from Us to choose a Dentist.

The PDP does not provide dental services. Whether or not benefits are available for a particular service, does not mean You should or should not receive the service. You and Your Dentist have the right and are responsible at all times for choosing the course of treatment and services to be performed. After services have been performed, We will determine the extent to which benefits, if any, are payable.

When requesting a Covered Service from an In-Network Dentist, We recommend that You:  

identify Yourself as an insured in the Preferred Dentist Program; and confirm that the Dentist is currently an In-Network Dentist at the time that the Covered Service is performed.

The amount of the benefit will not be affected by whether or not You identify Yourself as a member in the Preferred Dentist Program.

You can obtain a customized listing of MetLife’s In-Network Dentists either by calling 1-800-275-4638 or by visiting Our website at www.metlife.com/dental.

BENEFIT AMOUNTS We will pay benefits in an amount equal to the Covered Percentage for charges incurred by You or a Dependent for a Covered Service as shown in the SCHEDULE OF BENEFITS, subject to the conditions set forth in this certificate.

In-Network If a Covered Service is performed by an In-Network Dentist, We will base the benefit on the Covered Percentage of the Maximum Allowed Charge.

If an In-Network Dentist performs a Covered Service, You will be responsible for paying:  

the Deductible; and any other part of the Maximum Allowed Charge for which We do not pay benefits.

Out-of-Network If a Covered Service is performed by an Out-of-Network Dentist, We will base the benefit on the Covered Percentage of the Reasonable and Customary Charge.

Out-of-Network Dentists may charge You more than the Reasonable and Customary Charge. If an Out-ofNetwork Dentist performs a Covered Service, You will be responsible for paying:   

the Deductible; any other part of the Reasonable and Customary Charge for which We do not pay benefits; and any amount in excess of the Reasonable and Customary Charge charged by the Out-of-Network Dentist.

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DENTAL INSURANCE (CONTINUED) Maximum Benefit Amounts The Schedule of Benefits sets forth Maximum Benefit Amounts We will pay for Covered Services received InNetwork and Out-of-Network. We will never pay more than the greater of the In-Network Maximum Benefit Amount or the Out-of-Network Maximum Benefit Amount.

For example, if a Covered Service is received Out-of-Network and We pay $300 in benefits for such service, $300 will be applied toward both the In-Network and the Out-of-Network Maximum Benefit Amounts applicable to such service.

Deductibles The Deductible amounts are shown in the Schedule of Benefits.

The Yearly Individual Deductible is the amount that You and each Dependent must pay for Covered Services to which such Deductible applies each Year before We will pay benefits for such Covered Services.

We apply amounts used to satisfy Yearly Individual Deductibles to the Yearly Family Deductible. Once the Yearly Family Deductible is satisfied, no further Yearly Individual Deductibles are required to be met.

The amount We apply toward satisfaction of a Deductible for a Covered Service is the amount We use to determine benefits for such service. The Deductible Amount will be applied based on when Dental insurance claims for Covered Services are processed by Us. The Deductible Amount will be applied to Covered Services in the order that Dental Insurance claims for Covered Services are processed by Us regardless of when a Covered Service is “incurred”. When several Covered Services are incurred on the same date and Dental Insurance benefits are claimed as part of the same claim, the Deductible Amount is applied based on the Covered Percentage applicable to each Covered Service. The Deductible Amount will be applied in the order of highest Covered Percentage to lowest Covered Percentage.

Alternate Benefit If We determine that a service, less costly than the Covered Service the Dentist performed, could have been performed to treat a dental condition, We will pay benefits based upon the less costly service if such service:  would produce a professionally acceptable result under generally accepted dental standards; and  would qualify as a Covered Service.

For example:   

when a filling and an inlay are both professionally acceptable methods for treating tooth decay or breakdown, We may base Our benefit determination upon the filling which is the less costly service; when a filling and a crown are both professionally acceptable methods for treating tooth decay or breakdown, We may base Our benefit determination upon the filling which is the less costly service; and when a partial denture and fixed bridgework are both professionally acceptable methods for replacing multiple missing teeth in an arch, We may base Our benefit determination upon the partial denture which is the less costly service.

If We pay benefits based upon a less costly service in accordance with this subsection, the Dentist may charge You or Your Dependent for the difference between the service that was performed and the less costly service. This is the case even if the service is performed by an In-Network Dentist.

Certain comprehensive dental services have multiple steps associated with them. These steps can be completed at one time or during multiple sessions. For benefit purposes under this certificate, these separate steps of one service are considered to be part of the more comprehensive service. Even if the dentist submits separate bills, the total benefit payable for all related charges will be limited by the maximum benefit payable for the more comprehensive service. For example, root canal therapy includes x-rays, opening of the pulp chamber, additional x-rays, and filling of the chamber. Although these services may be performed in multiple sessions, they all constitute root canal therapy. Therefore, we will only pay benefits for the root canal therapy.

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DENTAL INSURANCE (CONTINUED) Orthodontic Covered Services Orthodontic treatment generally consists of initial placement of an appliance and periodic follow-up visits.

The benefit payable for the initial placement will not exceed 20% of the Maximum Benefit Amount for Orthodontia.

The benefit payable for the periodic follow-up visits will be based on the lower of:  the amount charged by the Dentist; and  the Maximum Benefit Amount for Orthodontia.

The benefit payable for the periodic follow-up visits will be payable on a monthly basis during the scheduled course of the orthodontic treatment if:  Dental Insurance is in effect for the person receiving the orthodontic treatment; and  proof is given to Us that the orthodontic treatment is continuing.

Benefits for Orthodontic Services Begun Prior to this Dental Insurance If the initial placement was made prior to this Dental Insurance being in effect, the benefit payable will be reduced by the portion attributable to the initial placement.

If the periodic follow-up visits commenced prior to this Dental Insurance being in effect:  the number of months for which benefits are payable will be reduced by the number of months of treatment performed before this Dental Insurance was in effect; and  the total amount of the benefit payable for the periodic visits will be reduced proportionately.

Pretreatment Estimate of Benefits If a planned dental service is expected to cost more than $300, You have the option of requesting a pretreatment estimate of benefits. The Dentist should submit a claim detailing the services to be performed and the amount to be charged. After We receive this information, We will provide You with an estimate of the Dental Insurance benefits available for the service. The estimate is not a guarantee of the amount We will pay. Under the Alternate Benefit provision, benefits may be based on the cost of a service other than the service that You choose. You are required to submit Proof on or after the date the dental service is completed in order for Us to pay a benefit for such service.

The pretreatment estimate of benefits is only an estimate of benefits available for proposed dental services.

You are not required to obtain a pretreatment estimate of benefits. As always, You or Your Dependent and the Dentist are responsible for choosing the services to be performed.

Benefits We Will Pay After Insurance Ends We will pay benefits for a 31 day period after Your Insurance ends for the completion of installation of a prosthetic device if:  

the Dentist prepared the abutment teeth or made impressions before Your Insurance ends; and the device is installed within 31 days after the date the Insurance ends.

We will pay benefits for a 31 day period after Your Insurance ends for the completion of installation of a Cast Restoration if:  

the Dentist prepared the tooth for the Cast Restoration before Your Insurance ends; and the Cast Restoration is installed within 31 days after the date the Insurance ends.

We will pay benefits for a 31 day period after Your Insurance ends for completion of root canal therapy if:  

the Dentist opened into the pulp chamber before Your Insurance ends; and the treatment is finished within 31 days after the date the Insurance ends.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES Type A Covered Services 1. Oral exams are limited to once every 6 months less the number of problem-focused examinations received during such months.

2. Screenings, including state or federally mandated screenings, to determine an individual's need to be seen by a dentist for diagnosis, are limited to once every 6 months.

3. Patient assessments (limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment), are limited to once every 6 months.

4. Problem-focused examinations are limited to once every 6 months less the number of oral exams received during such months.

5. Bitewing x-rays but not more than 1 set every 12 months.

6. Full mouth or panoramic x-rays once every 60 months.

7. Intraoral-periapical x-rays.

8. Dental x-rays except as mentioned elsewhere in this certificate.

9. Cleaning of teeth also referred to as oral prophylaxis (including full mouth scaling in presence of generalized moderate or severe gingival inflammation after oral evaluation) once every 6 months.

10. Topical fluoride treatment for a Child under age 14, but not more than twice in 12 months.

11. Sealants or sealant repairs for a Child under age 16, which are applied to non-restored, non-decayed first and second permanent molars, but not more than once per tooth every 36 months.

12. Preventive resin restorations, which are applied to non-restored first and second permanent molars, but not more than once per tooth every 36 months.

13. Interim caries arresting medicament application applied to permanent bicuspids and 1st and 2nd molar teeth, but not more than once per tooth every 36 months.

14. Space maintainers for a Child under age 16, once per lifetime per tooth area.

15. Emergency palliative treatment to relieve tooth pain.

16. Fixed and removable appliances for correction of harmful habits.

Type B Covered Services 1. Pulp vitality, diagnostic photographs, and bacteriological studies for determination of bacteriologic agents.

2. Collection and preparation of genetic sample material for laboratory analysis and report, but no more than once per lifetime.

3. Diagnostic casts.

4. Protective (sedative) fillings.

5. Initial placement of amalgam fillings.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (CONTINUED) 6. Replacement of an existing amalgam filling, but only if:  

at least 24 months have passed since the existing filling was placed; or a new surface of decay is identified on that tooth.

7. Initial placement of resin fillings.

8. Replacement of an existing resin filling, but only if:  

at least 24 months have passed since the existing filling was placed; or a new surface of decay is identified on that tooth.

9. Consultations for interpretation of diagnostic image by a Dentist not associated with the capture of the image, but not more than once in a 12 month period.

10. Other consultations, but not more than once in a 12 month period.

11. General anesthesia or intravenous sedation in connection with oral surgery, extractions or other Covered Services, when We determine such anesthesia is necessary in accordance with generally accepted dental standards.

12. Simple extractions.

13. Surgical extractions.

14. Oral surgery except as mentioned elsewhere in this certificate.

15. Pulp capping (excluding final restoration).

16. Pulp therapy.

17. Apexification/recalcification.

18. Therapeutic pulpotomy (excluding final restoration).

19. Root canal treatment, including bone grafts and tissue regeneration procedures in conjunction with periradicular surgery, but not more than once for the same tooth.

Other endodontic procedures, such as apicoectomy, retrograde fillings, root amputation, and hemisection.

20. Periodontal maintenance where periodontal treatment (including scaling, root planing, and periodontal surgery such as gingivectomy, gingivoplasty and osseous surgery) has been performed. Periodontal maintenance is limited two times in any calendar year less the number of teeth cleanings received during such calendar year.

21. Periodontal, non-surgical treatment such as scaling and root planing, but not more than once per quadrant in any 24 month period.

22. Periodontal surgery not mentioned elsewhere, including gingivectomy, gingivoplasty and osseous surgery, but no more than one surgical procedure per quadrant in any 36 month period.

23. Periodontal soft & connective tissue grafts, but no more than one surgical procedure per quadrant in any 36 month period.

24. Prefabricated crown, but no more than one replacement for the same tooth surface within 24 months.

25. Occlusal adjustments, but not more than once in a 12 month period.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (CONTINUED) 26. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards including adjustments and night guards.

Type C Covered Services 1. Tissue Conditioning, but not more than once in a 12 month period.

2. Initial installation of Cast Restorations (except an implant supported Cast Restoration).

3. Replacement of Cast Restorations (except an implant supported Cast Restoration), but only if at least 10 years have passed since the most recent time that:  

a Cast Restoration was installed for the same tooth surface; or a Cast Restoration for the same tooth surface was replaced.

4. Simple Repairs of Cast Restorations but not more than once in a 12 month period.

5. Core buildup, but no more than once per tooth in a period of 10 calendar years.

6. Labial veneers, but no more than once per tooth in a period of 10 calendar years.

7. Post and cores, but no more than once per tooth in a period of 10 calendar years.

8. Initial installation of fixed and permanent Denture: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

9. Replacement of a non-serviceable fixed and permanent Denture if such Denture was installed more than 10 calendar years prior to replacement.

10. Initial installation of full or removable Dentures: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

11. Replacement of an immediate, temporary full Denture with a permanent full Denture if the immediate, temporary full Denture cannot be made permanent and such replacement is done within 12 months of the installation of the immediate, temporary full Denture.

12. Replacement of a non-serviceable full or removable Denture if such Denture was installed more than 10 calendar years prior to replacement.

13. Adjustments of Dentures: 

if at least 6 months have passed since the installation of the existing removable Denture; and



not more than once in any 12 month period.

14. Relinings and rebasings of existing removable Dentures:  

if at least 6 months have passed since the installation of the existing removable Denture; and not more than once in any 24 month period.

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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (CONTINUED) 15. Repair of Dentures but not more than once in a 12 month period.

16. Addition of teeth to fixed and permanent Denture to replace natural teeth.

17. Addition of teeth to a partial removable Denture to replace natural teeth.

18. Re-cementing of Cast Restorations or Dentures but not more than once in a 12 month period.

19. Implant services (including sinus augmentation and bone replacement and graft for ridge preservation), but no more than once for the same tooth position in a 10 calendar year period: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

20. Cleaning and inspection of a removable appliance once every 6 months.

21. Repair of implants, but not more than once in a 10 calendar year period.

22. Implant supported prosthetics, but no more than once for the same tooth position in a 10 calendar year period: 

when needed to replace congenitally missing teeth; or



when needed to replace natural teeth.

23. Repair of implant supported prosthetics but not more than once in a 12 month period.

24. Local chemotherapeutic agents.

25. Injections of therapeutic drugs.

26. Application of desensitizing medicaments where periodontal treatment (including scaling, root planing, and periodontal surgery such as osseous surgery) has been performed.

27. Non-surgical treatment of temporomandibular joint disorders. This includes cone beam imaging but cone beam imaging for such treatment will not be covered more than once for the same tooth position in a 60 month period.

With respect to residents of Minnesota, Oral surgical and non-surgical treatment of Temporomandibular joint disorders (TMJ) and craniomandibular disorder. This includes cone beam imaging but cone beam imaging for such treatment will not be covered more than once for the same tooth position in a 60 month period.

Type D Covered Services Orthodontia, if the orthodontic appliance is initially installed while Dental Insurance is in effect for You, Your Spouse, and Your Children.

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DENTAL INSURANCE: EXCLUSIONS We will not pay Dental Insurance benefits for charges incurred for: 1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature; 2. Services for which You would not be required to pay in the absence of Dental Insurance; 3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 4. Services which are primarily cosmetic, unless required for the treatment or correction of a congenital defect of a newborn child.

5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: 

scaling and polishing of teeth; or



fluoride treatments.

6. Services or appliances which restore or alter occlusion or vertical dimension.

7. Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease.

8. Restorations or appliances used for the purpose of periodontal splinting.

9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.

10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.

11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.

12. Missed appointments.

13. Services: 

covered under any workers’ compensation or occupational disease law;



covered under any employer liability law;



for which the employer of the person receiving such services is not required to pay; or



received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

14. Services covered under other coverage provided by the Employer.

15. Temporary or provisional restorations.

16. Temporary or provisional appliances.

17. Prescription drugs.

18. Services for which the submitted documentation indicates a poor prognosis.

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DENTAL INSURANCE: EXCLUSIONS (CONTINUED) 19. Services, to the extent such services, or benefits for such services, are available under a Government Plan.

This exclusion will apply whether or not the person receiving the services is enrolled for the Government Plan. We will not exclude payment of benefits for such services if the Government Plan requires that Dental Insurance under the Group Policy be paid first.

Government Plan means any plan, program, or coverage which is established under the laws or regulations of any government.

The term does not include: 

any plan, program or coverage provided by a government as an employer; or



Medicare.

20. The following when charged by the Dentist on a separate basis: 

claim form completion;



infection control such as gloves, masks, and sterilization of supplies; or



local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.

21. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food.

22. Caries susceptibility tests.

23. Precision attachments, except when the precision attachment is related to implant prosthetics.

24. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it.

25. Repair or replacement of an orthodontic device.

26. Duplicate prosthetic devices or appliances.

27. Replacement of a lost or stolen appliance, Cast Restoration, or Denture.

28. Intra and extraoral photographic images.

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DENTAL INSURANCE: COORDINATION OF BENEFITS COORDINATION OF THIS CONTRACT'S BENEFITS WITH OTHER BENEFITS The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one Plan. Plan is defined below. The order of benefit determination rules govern the order in which each Plan will pay a claim for benefits. The Plan that pays first is called the primary Plan.

The primary Plan must pay benefits in accord with its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the primary Plan is the secondary Plan. The secondary Plan may reduce the benefits it pays so that payments from all Plans equal 100 percent of the total Allowable Expense.

DEFINITIONS (a) A "Plan" is any of the following that provides benefits or services for dental care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same Plan and there is no COB among those separate contracts.

(1) Plan includes: group, blanket, or franchise accident and health insurance policies, excluding disability income protection coverage; individual and group health maintenance organization evidences of coverage; individual accident and health insurance policies; individual and group preferred provider benefit Plans and exclusive provider benefit Plans; group insurance contracts, individual insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care; dental care components of individual and group long-term care contracts; limited benefit coverage that is not issued to supplement individual or group in-force policies; uninsured arrangements of group or group-type coverage; the dental benefits coverage in automobile insurance contracts; and Medicare or other governmental benefits, as permitted by law.

(2) Plan does not include: disability income protection coverage; the Texas Health Insurance Pool; workers' compensation insurance coverage; hospital confinement indemnity coverage or other fixed indemnity coverage; specified disease coverage; supplemental benefit coverage; accident only coverage; specified accident coverage; school accident-type coverages that cover students for accidents only, including athletic injuries, either on a "24-hour" or a "to and from school" basis; benefits provided in long-term care insurance contracts for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care, and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services; Medicare supplement policies; a state Plan under Medicaid; a governmental Plan that, by law, provides benefits that are in excess of those of any private insurance Plan; or other nongovernmental Plan; or an individual accident and health insurance policy that is designed to fully integrate with other policies through a variable deductible.

Each contract for coverage under (a)(1) or (a)(2) is a separate Plan. If a Plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate Plan. (b) "This Plan" means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other Plans. Any other part of the contract providing health care benefits is separate from This Plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with like benefits, and may apply other separate COB provisions to coordinate other benefits.

The order of benefit determination rules determine whether This Plan is a primary Plan or secondary Plan when the person has health care coverage under more than one Plan. When This Plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits. When This Plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits equal 100 percent of the total allowable expense.

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DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) (c) "Allowable expense" is a dental care expense, including deductibles, coinsurance, and copayments, that is covered at least in part by any Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any Plan covering the person is not an Allowable Expense. In addition, any expense that a provider by law in accordance with a contractual agreement is prohibited from charging a covered person is not an Allowable Expense.

The following are examples of expenses that are not Allowable Expenses: (1) If a person is covered by two or more Plans that do not have negotiated fees and compute their benefit payments based on the usual and customary fees, allowed amounts, or relative value schedule reimbursement methodology, or other similar reimbursement methodology, any amount in excess of the highest reimbursement amount for a specific benefit is not an Allowable Expense.â&#x20AC;?

(2) If a person is covered by two or more Plans that provide benefits or services on the basis of negotiated, an amount in excess of the highest of the negotiated fees is not an Allowable Expense.

(3) If a person is covered by one Plan that does not have negotiated fees and that calculates its benefits or services based on usual and customary fees, allowed amounts, relative value schedule reimbursement methodology, or other similar reimbursement methodology, and another Plan that provides its benefits or services based on negotiated fees, the primary Plan's payment arrangement must be the Allowable Expense for all Plans. However, if the health care provider or physician has contracted with the secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary Plan's payment arrangement and if the health care provider's or physician's contract permits, the negotiated fee or payment must be the Allowable Expense used by the secondary Plan to determine its benefits.

(4) The amount of any benefit reduction by the primary Plan because a covered person has failed to comply with the Plan provisions is not an Allowable Expense. Examples of these types of Plan provisions include second surgical opinions, prior authorization of admissions, and preferred provider arrangements. (d) "Allowed amount" is the amount of a billed charge that a carrier determines to be covered for services provided by a nonpreferred provider. The allowed amount includes both the carrier's payment and any applicable deductible, copayment, or coinsurance amounts for which the insured is responsible. (e) "Closed Panel Plan" is a Plan that provides dental care benefits to covered persons primarily in the form of services through a panel of health care providers and physicians that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other health care providers and physicians, except in cases of emergency or referral by a panel member. (f) "Custodial Parent" is the parent with the right to designate the primary residence of a child by a court order under the Texas Family Code or other applicable law, or in the absence of a court order, is the parent with whom the child resides more than one-half of the calendar year, excluding any temporary visitation.

When a person is covered by two or more Plans, the rules for determining the order of benefit payments are as follows:

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DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) ORDER OF BENEFIT DETERMINATION RULES (a) The primary Plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other Plan. (b) Except as provided in (c), a Plan that does not contain a COB provision that is consistent with this policy is always primary unless the provisions of both Plans state that the complying Plan is primary. (c) Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage must be excess to any other parts of the Plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base Plan hospital and surgical benefits, and insurance type coverages that are written in connection with a Closed Panel Plan to provide out-ofnetwork benefits. (d) A Plan may consider the benefits paid or provided by another Plan in calculating payment of its benefits only when it is secondary to that other Plan. (e) If the primary Plan is a Closed Panel Plan and the secondary Plan is not, the secondary Plan must pay or provide benefits as if it were the primary Plan when a covered person uses a noncontracted health care provider or physician, except for emergency services or authorized referrals that are paid or provided by the primary Plan. (f) When multiple contracts providing coordinated coverage are treated as a single Plan under this subchapter, this section applies only to the Plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the Plan, the carrier designated as primary within the Plan must be responsible for the Plan's compliance with this subchapter. (g) If a person is covered by more than one secondary Plan, the order of benefit determination rules of this subchapter decide the order in which secondary Plans' benefits are determined in relation to each other. Each secondary Plan must take into consideration the benefits of the primary Plan or Plans and the benefits of any other Plan that, under the rules of this contract, has its benefits determined before those of that secondary Plan. (h) Each Plan determines its order of benefits using the first of the following rules that apply.

(1) Nondependent or Dependent. The Plan that covers the person other than as a dependent, for example as an employee, member, policyholder, subscriber, or retiree, is the primary Plan, and the Plan that covers the person as a dependent is the secondary Plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent and primary to the Plan covering the person as other than a dependent, then the order of benefits between the two Plans is reversed so that the Plan covering the person as an employee, member, policyholder, subscriber, or retiree is the secondary Plan and the other Plan is the primary Plan. An example includes a retired employee.

(2) Dependent Child Covered Under More Than One Plan. Unless there is a court order stating otherwise, Plans covering a Dependent Child must determine the order of benefits using the following rules that apply.

(A) For a Dependent Child whose parents are married or are living together, whether or not they have ever been married: (i) The Plan of the parent whose birthday falls earlier in the calendar year is the primary Plan; or (ii) If both parents have the same birthday, the Plan that has covered the parent the longest is the primary Plan.

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DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) (B) For a Dependent Child whose parents are divorced, separated, or not living together, whether or not they have ever been married: (i) if a court order states that one of the parents is responsible for the Dependent Child's health care expenses or health care coverage and the Plan of that parent has actual knowledge of those terms, that Plan is primary. This rule applies to Plan years commencing after the Plan is given notice of the court decree. (ii) if a court order states that both parents are responsible for the Dependent Child's health care expenses or health care coverage, the provisions of (h)(2)(A) must determine the order of benefits. (iii) if a court order states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the Dependent Child, the provisions of (h)(2)(A) must determine the order of benefits. (iv) if there is no court order allocating responsibility for the Dependent Child's health care expenses or health care coverage, the order of benefits for the Child are as follows: (I) the Plan covering the custodial parent; (II) the Plan covering the spouse of the custodial parent; (III) the Plan covering the noncustodial parent; then (IV) the Plan covering the spouse of the noncustodial parent.

(C) For a Dependent Child covered under more than one Plan of individuals who are not the parents of the Child, the provisions of (h)(2)(A) or (h)(2)(B) must determine the order of benefits as if those individuals were the parents of the Child.

(D) For a Dependent Child who has coverage under either or both parents' Plans and has his or her own coverage as a dependent under a spouse's Plan, (h)(5) applies.

(E) In the event the Dependent Child's coverage under the spouse's Plan began on the same date as the Dependent Child's coverage under either or both parents' Plans, the order of benefits must be determined by applying the birthday rule in (h)(2)(A) to the dependent Child's parent(s) and the dependent's spouse.]

(3) Active, Retired, or Laid-off Employee. The Plan that covers a person as an active employee, that is, an employee who is neither laid off nor retired, is the Primary Plan. The Plan that covers that same person as a retired or laid-off employee is the secondary Plan. The same would hold true if a person is a dependent of an active employee and that same person is a dependent of a retired or laid-off employee. If the Plan that covers the same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule does not apply. This rule does not apply if (h)(1) can determine the order of benefits.

(4) COBRA or State Continuation Coverage. If a person whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another Plan, the Plan covering the person as an employee, member, subscriber, or retiree or covering the person as a dependent of an employee, member, subscriber, or retiree is the primary Plan, and the COBRA, state, or other federal continuation coverage is the secondary Plan. If the other Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule does not apply. This rule does not apply if (h)(1) can determine the order of benefits.

(5) Longer or Shorter Length of Coverage. The Plan that has covered the person as an employee, member, policyholder, subscriber, or retiree longer is the primary Plan, and the Plan that has covered the person the shorter period is the secondary Plan.

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DENTAL INSURANCE: COORDINATION OF BENEFITS (CONTINUED) (6) If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the Plans meeting the definition of Plan. In addition, This Plan will not pay more than it would have paid had it been the primary Plan.

EFFECT ON THE BENEFITS OF THIS PLAN (a) When This Plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Plans are not more than the total allowable expenses. In determining the amount to be paid for any claim, the secondary Plan will calculate the benefits it would have paid in the absence of other health care coverage and apply that calculated amount to any allowable expense under its Plan that is unpaid by the primary Plan. The secondary Plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary Plan, the total benefits paid or provided by all Plans for the claim equal 100 percent of the total allowable expense for that claim. In addition, the secondary Plan must credit to its Plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage. (b) If a covered person is enrolled in two or more closed panel Plans and if, for any reason, including the provision of service by a nonpanel provider, benefits are not payable by one closed panel Plan, COB must not apply between that Plan and other closed panel Plans.

COMPLIANCE WITH FEDERAL AND STATE LAWS CONCERNING CONFIDENTIAL INFORMATION Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under This Plan and other Plans. We will comply with federal and state law concerning confidential information for the purpose of applying these rules and determining benefits payable under This Plan and other Plans covering the person claiming benefits. Each person claiming benefits under This Plan must give Us any facts it needs to apply those rules and determine benefits.

FACILITY OF PAYMENT A payment made under another Plan may include an amount that should have been paid under This Plan. If it does, We may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means the reasonable cash value of the benefits provided in the form of services.

RIGHT OF RECOVERY If the amount of the payments made by Us is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid or any other person or organization that may be responsible for the benefits or services provided for the covered person. The "amount of the payments made" includes the reasonable cash value of any benefits provided in the form of services.

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FILING A CLAIM For Dental Insurance, all claim forms needed to file for benefits under the group insurance program can be obtained by calling MetLife at 1-800-275-4638. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim.

When We receive the claim form and Proof, We will review the claim and, if We approve it, We will pay benefits subject to the terms and provisions of this certificate and the Group Policy.

CLAIMS FOR DENTAL INSURANCE BENEFITS When a claimant files a claim for Dental Insurance benefits described in this certificate, both the notice of claim and the required Proof should be sent to Us within 90 days of the date of a loss.

Claim and Proof may be given to Us by following the steps set forth below: Step 1 A claimant can request a claim form by calling Us at 1-800-275-4638.

Step 2 We will send a claim form to the claimant within 15 days of the request. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim.

Step 3 When the claimant receives the claim form the claimant should fill it out as instructed and return it with the required Proof described in the claim form.

Step 4 The claimant must give Us Proof not later than 90 days after the date of the loss.

If notice of claim or Proof is not given within the time limits described in this section, the delay will not cause a claim to be denied or reduced if such notice and Proof are given as soon as is reasonably possible.

Time Limit on Legal Actions. A legal action on a claim for Dental Insurance benefits may only be brought against Us during a certain period. This period begins 60 days after the date Proof is filed and ends 3 years after the date such Proof is required.

GCERT2000 claim 10/04 58 ASPEN 2018 BENEFITS :: 275

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS Procedures for Presenting Claims for Dental Insurance Benefits All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Routine Questions on Dental Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-800-275-4638.

Claim Submission For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination After You submit a claim for Dental Insurance benefits to MetLife, MetLife will notify You acknowledging receipt of Your claim, commence with any investigation, and request any additional information within 15 days of receipt of Your claim.

MetLife will notify You in writing of the acceptance or rejection of Your claim within 15 business days of receipt of all information needed to process Your claim.

If MetLife cannot accept or reject Your claim within 15 business days after receipt of all information, MetLife will notify You within 15 business days stating the reason why we require an extension. If an extension is requested, We will notify You of our decision to approve or deny Your claim within 45 days. Upon notification of approval, Your claim will be paid within 5 business days.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Appealing the Initial Determination If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision. Appeals must be in writing and must include at least the following information:     

Name of Employee Name of the Plan Reference to the initial decision Whether the appeal is the first or second appeal of the initial determination An explanation why You are appealing the initial determination.

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

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DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS (CONTINUED) After MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials, and MetLifeâ&#x20AC;&#x2122;s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify You in writing of its final decision within 30 days after MetLifeâ&#x20AC;&#x2122;s receipt of Your written request for review, except that under special circumstances MetLife may have up to an additional 30 days to provide written notification of the final decision. If such an extension is required, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason(s) why such an extension is needed, and state when it will make its determination.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

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GENERAL PROVISIONS Assignment The rights and benefits under the Group Policy are not assignable prior to a claim for benefits, except as required by law.

Upon receipt of a Covered Service, You may assign Dental Insurance benefits to the Dentist providing such service.

Dental Insurance: Who We Will Pay If You assign payment of Dental Insurance benefits to Your or Your Dependentâ&#x20AC;&#x2122;s Dentist, We will pay benefits directly to the Dentist. Otherwise, We will pay Dental Insurance benefits to You. Entire Contract Your insurance is provided under a contract of group insurance with the Employer. The entire contract with the Employer is made up of the following: 1. the Group Policy and its Exhibits, which include the certificate(s); 2. the Employer's application; and 3. any amendments and/or endorsements to the Group Policy.

Incontestability: Statements Made by You Any statement made by You will be considered a representation and not a warranty. We will not use such statement to avoid insurance, reduce benefits or defend a claim unless the following requirements are met: 1. the statement is in a Written application or enrollment form; 2. You have Signed the application or enrollment form; and 3. a copy of the application or enrollment form has been given to You or Your Beneficiary.

Misstatement of Age If Your age is misstated, the correct age will be used to determine if insurance is in effect and, as appropriate, We will adjust the benefits and/or premiums.

Conformity with Law If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be interpreted to so conform.

Autopsy We have the right to make a reasonable request for an autopsy where permitted by law. Any such request will set forth the reasons We are requesting the autopsy.

Overpayments Recovery of Dental Insurance Overpayments We have the right to recover any amount that We determine to be an overpayment, whether for services received by You or Your Dependents.

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GENERAL PROVISIONS (CONTINUED) An overpayment occurs if We determine that: 

the total amount paid by Us on a claim for Dental Insurance is more than the total of the benefits due to You under this certificate; or



payment We made should have been made by another group plan.

If such overpayment occurs, You have an obligation to reimburse Us. How We Recover Overpayments We may recover the overpayment from You by:   

stopping or reducing any future benefits payable for Dental Insurance; demanding an immediate refund of the overpayment from You; and taking legal action.

We may recover such overpayment in accordance with that agreement.

If the overpayment results from Our having made a payment to You that should have been made under another group plan, We may recover such overpayment from one or more of the following:   

any other insurance company; any other organization; or any person to or for whom payment was made.

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"THIS IS THE END OF THE CERTIFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION"

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THIS SUMMARY PLAN DESCRIPTION IS EXPRESSLY MADE PART OF THE PLAN AND IS LEGALLY ENFORCEABLE AS PART OF THE PLAN WITH RESPECT TO ITS TERMS AND CONDITIONS. IN THE EVENT THERE IS NO OTHER PLAN DOCUMENT, THIS DOCUMENT SHALL SERVE AS A SUMMARY PLAN DESCRIPTION AND SHALL ALSO CONSTITUTE THE PLAN.

ERISA INFORMATION NAME OF THE PLAN BRG Management Inc dba Aspen Heights Welfare Benefit Plan ("Plan") NAME AND ADDRESS OF EMPLOYER BRG Management Inc dba Aspen Heights 1301 S Capital of Texas Hwy Austin, TX 78746 (512) 369-3030 EMPLOYER IDENTIFICATION NUMBER: 262458511 COVERAGE

PLAN NAME

Dental Insurance

BRG Management Inc dba Aspen Heights Welfare Benefit Plan

TYPE OF ADMINISTRATION The above listed benefits are insured by Metropolitan Life Insurance Company ("MetLife").

PLAN ADMINISTRATOR NAME, BUSINESS ADDRESS AND PHONE NUMBER BRG Management Inc dba Aspen Heights 1301 S Capital of Texas Hwy Austin, TX 78746 (512) 369-3030 AGENT FOR SERVICE OF LEGAL PROCESS For disputes arising under the Plan, service of legal process may be made upon the Plan Administrator at the above address. For disputes arising under those portions of the Plan insured by MetLife, service of legal process may be made upon MetLife at one of its local offices, or upon the supervisory official of the Insurance Department in the state in which you reside.

ELIGIBILITY FOR PARTICIPATION; DESCRIPTION OR SUMMARY OF BENEFITS Your MetLife certificate describes the eligibility requirements for insurance provided by MetLife under the Plan. It also includes a detailed description of the insurance provided by MetLife under the Plan.

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The following applies to employers with 20 or more employees that are not church or government plans: NOTICE OF YOUR RIGHT AND YOUR DEPENDENTS' RIGHT TO COBRA CONTINUATION COVERAGE COBRA is a federal law that requires most group health plans to give their employees and their dependents the opportunity to continue coverage when coverage is terminated due to certain specific events. If your employment terminates for any reason other than your gross misconduct, or if your hours worked are reduced so that your coverage terminates, you and your covered dependents may be able to continue coverage under This Plan for a period of up to 18 months. If it is determined under the terms of the Social Security Act that You or your covered dependent is disabled within the first 60 days of COBRA coverage, you and your covered dependents may be able to continue your dental coverage under This Plan for an additional 11 months after the expiration of the 18 month period. In addition, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents may be able to continue coverage under This Plan for up to 36 months. Also, your covered children may be able to continue coverage under This Plan for up to 36 months after they no longer qualify as covered dependents under the terms of This Plan. Group health plans for employers with fewer than 20 employees, church plans, and plans established and maintained by the federal government are not subject to COBRA continuation requirements.

During the continuation period, a child of yours that is (1) born; (2) adopted by you; or (3) placed with you for adoption, will be treated as if the child were a covered dependent at the time coverage was lost due to an event described above.

This continuation will terminate on the earliest of: a. the end of the 18, 29 or 36 month continuation period, as the case may be; b. the date of expiration of the last period for which the required payment was made; c.

the date, after you or your covered dependent elects to continue coverage, that you or your covered dependent first becomes covered under another group health plan as long as the new plan does not contain any exclusion or limitation with respect to your or your covered dependentâ&#x20AC;&#x2122;s preexisting condition;

d. the date your employer ceases to provide any group health plan for its employees.

Notice will be given when you or your covered dependent becomes entitled to continue coverage under This Plan. You or your covered dependent will then have 60 days to elect to continue coverage. If you or your covered dependent do not notify your Employer within the 60-day election period, you will lose the option to elect continuation coverage.

Each person who is eligible for COBRA coverage is entitled to make a separate election of COBRA coverage.

Thus, a covered spouse (as defined by federal law) or dependent child (or parent on their behalf) is entitled to elect COBRA coverage even if the covered Employee does not make that election. However, covered Employees may elect COBRA coverage on behalf of their covered dependents. Any person who elects to continue coverage under This Plan must pay the full cost of that coverage (including both the share you now pay and the share your Employer now pays), plus any additional amounts permitted by law. Your payments for continued coverage must be made on the first day of each month in advance.

If you do not elect COBRA coverage, your dental coverage will end. However, if you initially waive COBRA continuation coverage before the end of the 60-day election period, you may change your election by sending the completed election form to the Plan Administrator and postmarking it no later than the last day of the 60day election period.

If You Elect Cobra If you choose COBRA coverage and pay the required premiums, you are entitled to coverage which, as of the time coverage is being provided, is identical to the coverage provided by the Employer to similarly situated active Employees, spouses or dependent children. This means that if the coverage for similarly situated Employees, spouses or dependent children changes, coverage will change for those who elected COBRA coverage.

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Duration Of Cobra Coverage The law requires that you be given the opportunity to maintain COBRA coverage for 36 months from the date coverage ends as a result of the qualifying event unless you lost coverage because of the covered Employee's termination of employment or reduction in hours. In that case, the required COBRA coverage period is 18 months from the date you lose coverage as a result of the termination of employment or reduction in hours. However, the 18-month coverage period may be extended under the following circumstances: Disability. If any person entitled to COBRA coverage (the covered Employee, covered spouse or covered dependent child) is determined by the Social Security Administration to have been disabled at any time during the first 60 days of COBRA coverage period and the disability lasts at least until the end of the 18 month period of continuation coverage, then all such persons entitled to elect COBRA coverage may be able to continue coverage for up to 29 months, rather than 18 months.

In order to be eligible for the additional 11 months of COBRA coverage, the covered Employee, covered spouse or covered dependent child must notify the Employer's COBRA Administrator within 60 days of the latest of: (1) the Social Security Administration’s determination of disability; (2) the date of the qualifying event; (3) the date on which the covered Employee’s coverage initially was or will be lost; or (4) the date a person entitled to COBRA coverage is informed of this obligation by being provided the initial COBRA notice for the applicable group health plan. Written notice to the COBRA Administrator must be received before the end of the initial 18-month coverage period. A copy of the Social Security Administration’s determination must be provided to the COBRA Administrator. If these procedures are not followed, there will be no disability extension of COBRA. During the additional 11 months of coverage, your cost for that coverage will be approximately 50% higher than it was during the preceding 18 months.

The additional 11 months of coverage provided on account of a disability will end as of the earlier of: 

The first day of the month beginning more than 30 days after a final determination by the Social Security Administration that the disability no longer exists; or



The last day of the 29th month of total coverage.

A person entitled to COBRA coverage must notify the COBRA Administrator within 30 days if the Social Security Administration determines that the disabled person is no longer disabled. This Plan reserves the right to retroactively cancel COBRA coverage, and will require reimbursement of all benefits paid for claims incurred after coverage terminates.

Subsequent Qualifying Events. If, during the 18-month period of COBRA coverage (or within the 29-month maximum coverage period in the case of a disability extension), the covered Employee and the spouse divorce, the covered Employee dies, the covered Employee becomes entitled to Medicare, or a dependent ceases to be an eligible dependent under the terms of This Plan, then the covered spouse and/or covered dependent child(ren) (as applicable) may be able to extend COBRA coverage for up to 36 months from the date of the termination of employment or reduction in hours.

A person entitled to COBRA coverage must notify the Employer’s COBRA Administrator of the subsequent event no later than 60 days after its occurrence. If such notification is not given, the covered spouse and/or covered dependent child will not be entitled to the additional COBRA coverage.

Premiums For Cobra Coverage A person entitled to COBRA coverage is entirely responsible for paying the premiums for COBRA coverage.

The required payment for each continuation coverage period for each option will be described in the notice that is sent when an individual experiences a qualifying event.

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Initial Premium Payment If continuation of coverage is elected, payment for continuation coverage must be made no later than 45 days after the date of such election. (This is the date the election notice is post-marked, if mailed.) If the first payment for continuation coverage is not made in full by the 45th day after the date of election, continuation coverage under This Plan will end. A person entitled to COBRA coverage is responsible for making sure that the amount of the first payment is correct.

After the first payment for continuation coverage, the amount due for each coverage period for each qualified beneficiary will be provided when coverage is elected.

PLAN TERMINATION OR CHANGES Written notice of termination must be given to the Employer at least 31 days prior to the date such insurance will be terminated.

Premiums are due and payable on the first day of each month for which insurance coverage is to be provided.

If a payment is not received within 31 days after the due date, coverage will terminate as follows: a. with respect to coverages other than Life Insurance and Accidental Death or Dismemberment Insurance on the earlier of the 31st day following the due date and the date requested in writing by the Employer, provided such request is made before such 31st day; and b. with respect to Life Insurance and Accidental Death or Dismemberment Insurance -- on the later of the 31st day following the due date and the date MetLife's written notice of termination is received by the Employer.

The Employer is liable to MetLife for payment of the pro-rata premium which accrues while any coverage remains in force.

The group policy sets forth those situations in which the Employer and/or MetLife have the right to end the policy.

The Employer reserves the right to change or terminate the Plan at any time. Therefore, there is no guarantee that you will be eligible for the benefits described herein for the duration of your employment. Any such action will be taken only after careful consideration.

Your consent or the consent of your beneficiary is not required to terminate, modify, amend, or change the Plan.

In the event Your coverage ends in accord with the Date Your Insurance Ends provision of Your certificate, you may still be eligible to receive benefits. The circumstances under which benefits are available are described in Your MetLife certificate.

CONTRIBUTIONS You must make a contribution to the cost of Personal and Dependent Dental Insurance.

The total premium rate for insurance provided under the Plan by MetLife is set by MetLife.

PLAN YEAR The Plan's fiscal records are kept on a Plan year basis beginning each January 01 and ending on the following December 31.

Qualified Domestic Relations Orders/Qualified Medical Child Support Orders You and your beneficiaries can obtain, without charge, from the Plan Administrator a copy of any procedures governing Qualified Domestic Relations Orders (QDRO) and Qualified Medical Child Support Orders (QMCSO).

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Dental Benefits Claims Procedures for Presenting Claims for Dental Benefits All claim forms needed to file for benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist you or, if applicable, your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental.

Routine Questions If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1800-275-4638.

Claim Submission For claims for dental benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the Filing a Claim section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination After you submit a claim for dental benefits to MetLife, MetLife will review your claim and notify you of its decision to approve or deny your claim.

Such notification will be provided to you within a 30 day period from the date you submitted your claim; except for situations requiring an extension of time of up to 15 days because of matters beyond the control of the Plan. If MetLife needs such an extension, MetLife will notify you prior to the expiration of the initial 30 day period, state the reason why the extension is needed, and state when it will make its determination. If an extension is needed because you did not provide sufficient information or filed an incomplete claim, the time from the date of MetLife's notice requesting further information and an extension until MetLife receives the requested information does not count toward the time period MetLife is allowed to notify you as to its claim decision. You will have 45 days to provide the requested information from the date you receive the notice requesting further information from MetLife.

If MetLife denies your claim in whole or in part, the notification of the claims decision will state the reason why your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that you may request a copy free of charge.

Appealing the Initial Determination If MetLife denies your claim, you may take two appeals of the initial determination. Upon your written request, MetLife will provide you free of charge with copies of documents, records and other information relevant to your claim. You must submit your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife's decision. Appeals must be in writing and must include at least the following information: 

Name of Employee



Name of the Plan



Reference to the initial decision



Whether the appeal is the first or second appeal of the initial determination



An explanation why you are appealing the initial determination

As part of each appeal, you may submit any written comments, documents, records, or other information relating to your claim.

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After MetLife receives your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of your claim. Deference will not be given to initial denials, and MetLife's review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that you submit relating to your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review your appeal will not be the same person as the person who made the initial decision to deny your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify you in writing of its final decision within 30 days after MetLife's receipt of your written request for review, except that under special circumstances MetLife may have up to an additional 30 days to provide written notification of the final decision. If such an extension is required, MetLife will notify you prior to the expiration of the initial 30 day period, state the reason(s) why such an extension is needed, and state when it will make its determination.

If MetLife denies the claim on appeal, MetLife will send you a final written decision that states the reason(s) why the claim you appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that you may request a copy free of charge.

Upon written request, MetLife will provide you free of charge with copies of documents, records and other information relevant to your claim.

When the claim has been processed, you will be notified of the benefits paid. If any benefits have been denied, you will receive a written explanation.

Urgent Care Claim Submission A small number of claims for dental benefits may be urgent care claims. Urgent care claims for dental benefits are claims for reimbursement of dental expenses for services which a dentist familiar with the dental condition determines would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Of course any such claim may always be submitted in accordance with the normal claim procedures. However your dentist may also submit such a claim to MetLife by telephoning MetLife and informing MetLife that the claim is an Urgent Care Claim. Urgent Care Claims are processed according to the procedures set out above, however once a claim for urgent care is submitted, MetLife will notify you of the determination on the claim as soon as possible, but no later than 72 hours after the claim was filed. If you or your covered dependent does not provide the claims administrator with enough information to decide the claim, MetLife will notify you within 24 hours after it receives the claim of the further information that is needed. You will have 48 hours to provide the information. If the needed information is provided, MetLife will then notify you of the claim decision within 48 hours after MetLife received the information. If the needed information is not provided, MetLife will notify you or your covered dependent of its decision within 120 hours after the claim was received.

If your urgent care claim is denied but you receive the care, you may appeal the denial using the normal claim procedures. If your urgent care claim is denied and you do not receive the care, you can request an expedited appeal of your claim denial by phone or in writing. MetLife will provide you any necessary information to assist you in your appeal. MetLife will then notify you of its decision within 72 hours of your request in writing. However, MetLife may notify you by phone within the time frames above and then mail you a written notice.

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Discretionary Authority of Plan Administrator and Other Plan Fiduciaries In carrying out their respective responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

STATEMENT OF ERISA RIGHTS The following statement is required by federal law and regulation.

As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan administrator's office and at other specified locations, all Plan documents governing the Plan, including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefit Security Administration.

Obtain, upon written request to the Plan administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the Plan's annual financial report. The Plan administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue Group Dental Plan Insurance Continue dental insurance for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.

Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.

No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan administrator to provide the materials and pay you up to $110.00 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court.

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In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court.

If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court.

The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees.

If you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is frivolous.

Assistance with Your Questions If you have any questions about your Plan, you should contact the Plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

PLAN PRIVACY INFORMATION Notwithstanding any other Plan provision in this or other sections of the Plan, the Plan will operate in accordance with the HIPAA privacy laws and regulations as set forth in 45 CFR Parts 160 and 164, and as they may be amended ("HIPAA"), with respect to protected health information ("PHI") as that term is defined therein. The Plan Administrator and/or his or her designee retains full discretion in interpreting these rules and applying them to specific situations. All such decisions shall be given full deference unless the decision is determined to be arbitrary and capricious.

The term “Plan Sponsor” means BRG Management Inc. The term “Plan Administrator” means the entity designated as Plan Administrator by the Plan documents pursuant to which the plan is operated. If a Plan Administrator is not designated by the plan documents, the Plan Sponsor shall be deemed to be the Plan Administrator.

I. Permitted Uses and Disclosures of PHI by the Plan and the Plan Sponsor The Plan and the Plan Sponsor are permitted to use and disclose PHI for the following purposes, to the extent they are not inconsistent with HIPAA: 

For general plan administration, including policyholder service functions, enrollment and eligibility functions, reporting functions, auditing functions, financial and billing functions, to assist in the administration of a consumer dispute or inquiry, and any other authorized insurance or benefit function.



As required for computer programming, consulting or other work done in respect to the computer programs or systems utilized by the Plan.



Other uses relating to plan administration, which are approved in writing by the Plan Administrator.



At the request of an individual, to assist in resolving claims the individual may have with respect to benefits under the Plan.

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II. Uses and Disclosures of PHI by the Plan and the Plan Sponsor for Required Purposes The Plan and Plan Sponsor may use or disclose PHI for the following required purposes: 

Judicial and administrative proceedings, in response to lawfully executed process, such as a court order or subpoena.



For public health and health oversight activities, and other governmental activities accompanied by lawfully executed process.



As otherwise may be required by law.

III. Sharing of PHI With the Plan Sponsor

As a condition of the Plan Sponsor receiving PHI from the Plan, the Plan Documents have been amended to incorporate the following provisions, under which the Plan Sponsor agrees to: 

Not use or further disclose PHI other than as permitted or required by the plan documents in Sections I and II above;



Ensure that any agents to whom it provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor;



Not use or disclose PHI for employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor;



Report to the Plan any use or disclosure of the information that is inconsistent with the permitted uses or disclosures of which it becomes aware;



Make PHI available to Plan participants for the purposes of the rights of access and inspection, amendment, and accounting of disclosures as required by HIPAA;



Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the Plan with HIPAA;



If feasible, return or destroy all PHI received from the Plan that the sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible;



Ensure that adequate separation between the Plan and Plan Sponsor is established in accordance with the following requirements: (A) Employees to be Given Access to PHI: The following employees (or class of employees) of the Plan Sponsor are the only individuals that may access PHI provided by the Plan: Human Resource Director (B) Restriction to Plan Administration Functions: The access to and use of PHI by the employees of the Plan Sponsor designated above will be limited to plan administration functions that the Plan Sponsor performs for the Plan.

(C) Mechanism for Resolving issues of Noncompliance: If the Plan Administrator determines that an employee of the Plan Sponsor designated above has acted in noncompliance with the plan document provisions outlined above, then the Plan Administrator shall take or seek to have taken appropriate disciplinary action with respect to that employee, up to and including termination of employment as ASPEN 2018 BENEFITS :: 289

appropriate. The Plan Administrator shall also document the facts of the violation, actions that have been taken to discipline the offending party and the steps taken to prevent future violations.

Certify to the Plan, prior to the Plan permitting disclosure of PHI to the Plan Sponsor, that the Plan Documents have been amended to incorporate the provisions in this Section.

IV. Security As a condition of the Plan Sponsor receiving electronic PHI (“ePHI”) from the Plan, the Plan Documents have been amended to incorporate the following provisions, under which the Plan Sponsor agrees to: 

Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the ePHI that it creates, receives, maintains, or transmits on behalf of the Plan;



Ensure that the adequate separation between the Plan and the Plan Sponsor, which is required by the applicable section(s) of the Plan relating to the sharing of PHI with the Plan Sponsor, is supported by reasonable and appropriate security measures;



Ensure that any agent to whom it provides ePHI agrees to implement reasonable and appropriate security measures to protect the information; and



Report to the Plan any security incident of which it becomes aware. In this context, the term “security incident” means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in information systems such as hardware, software, information, data, applications, communications, and people.

FUTURE OF THE PLAN

It is hoped that This Plan will be continued indefinitely, but BRG Management Inc dba Aspen Heights reserves the right to change or terminate the Plan in the future. Any such action would be taken only after careful consideration.

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Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally.

Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals.

Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access.

We comply with all laws that apply to us.

Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses.

How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.

Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to:       

administer your products and services process claims and other transactions perform business research confirm or correct your information market new products to you help us run our business comply with applicable laws

Sharing Your Information With Others We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.

Other reasons we may share your information include:    

doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) telling another company what we know about you if we are selling or merging any part of our business giving information to a governmental agency so it can decide if you are eligible for public benefits giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account)

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  

giving your information to your health care provider having a peer review organization evaluate your information, if you have health coverage with us those listed in our “Using Your Information” section above HIPAA

We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance.

Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you.

You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. Select “Privacy Policy” at the bottom of the home page. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAprivacyAmericasUS@metlife.com, or call us at telephone number (212) 578-0299.

Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law.

If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife.

Questions/More Information We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us.

When you write, include your name, address, and policy or account number.

Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI 02887-9954 privacy@metlife.com We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies: Metropolitan Life Insurance Company MetLife Insurance Company USA SafeGuard Health Plans, Inc.

MetLife Health Plans, Inc. General American Life Insurance Company SafeHealth Life Insurance Company

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Uniformed Services Employment And Reemployment Rights Act This section describes the right that you may have to continue coverage for yourself and your covered dependents under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).

Continuation of Group Dental Insurance: If you take a leave from employment for “service in the uniformed services,” as that term is defined in USERRA, and as a consequence your dental insurance coverage under your employer’s group dental insurance policy ends, you may elect to continue dental insurance for yourself and your covered dependents, for a limited period of time, as described below.

The law requires that your employer notify you of your rights, benefits and obligations under USERAA including instructions on how to elect to continue insurance, the amount and procedure for payment of premium. If permitted by USERRA, your employer may require that you elect to continue coverage within a period of time specified by your employer.

You may be responsible for payment of the required premium to continue insurance. If your leave from employment for service in the uniformed services lasts less than 31 days, your required premium will be no more than the amount you were required to pay for dental insurance before the leave began; for a leave lasting 31 or more days, you may be required to pay up to 102% of the total dental insurance premium, including any amount that your employer was paying before the leave began.

You and your covered dependents insurance that is continued pursuant to USERRA will end on the earliest of the following:  

the end of 24 consecutive months from the date your leave from employment for service in the uniformed services begins; or the day after the date on which you fail to apply for, or return to employment, in accordance with USERRA.

You and your covered dependent may become entitled to continuation of coverage under the Consolidated Omnibus Budget Reconciliation Act (“COBRA”) while you have dental insurance coverage under your employer’s group dental insurance policy pursuant to USERRA. Contact your employer for more information.

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Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166

CERTIFICATE OF INSURANCE Metropolitan Life Insurance Company ("MetLife"), a stock company, certifies that You and Your Dependents are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY. This certificate is part of the Group Policy. The Group Policy is a contract between MetLife and the Employer and may be changed or ended without Your consent or notice to You. This certificate describes insurance provided by a certificate previously issued to You by MetLife and replaces such previous certificate.

Employer:

BRG Management Inc dba Aspen Heights

Group Policy Number:

KM 05932994-G

Type of Insurance:

Vision Insurance

MetLife Toll Free Number(s): For Claim Information

1-855-METEYE1

THIS CERTIFICATE ONLY DESCRIBES VISION INSURANCE. FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED. THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE LAW OF A STATE OTHER THAN FLORIDA. THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS REQUIRED BY MARYLAND LAW. WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) CAREFULLY.

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IMPORTANT NOTICE

AVISO IMPORTANTE

To obtain information or make a complaint:

Para obtener información o para presentar una queja:

You may call MetLife’s toll free telephone number for information or to make a complaint at:

Usted puede llamar al número de teléfono gratuito de MetLife’s para obtener información o para presentar una queja al:

1-800-275-4638

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights, or complaints at:

1-800-252-3439

1-800-275-4638

Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre compañías, coberturas, derechos, o quejas al:

1-800-252-3439

You may write the Texas Department of Insurance:

Usted puede escribir al Departamento de Seguros de Texas a:

P.O. Box 149104 Austin, TX 78714-9104 Fax : (512) 490-1007

P.O. Box 149104 Austin, TX 78714-9104 Fax : (512) 490-1007

Web: www.tdi.texas.gov

Sitio web: www.tdi.texas.gov

Email: ConsumerProtection@tdi.texas.gov

Email: ConsumerProtection@tdi.texas.gov

PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact MetLife first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

DISPUTAS POR PRIMAS DE SEGUROS O RECLAMACIONES: Si tiene una disputa relacionada con su prima de seguro o con una reclamación, usted debe comunicarse con MetLife primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas.

ATTACH THIS NOTICE TO YOUR CERTIFICATE: This notice is for information only and does not become a part or condition of the attached document.

ADJUNTE ESTE AVISO A SU CERTIFICADO: Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto.

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NOTICE FOR RESIDENTS OF ALL STATES THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.

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NOTICE FOR RESIDENTS OF ARKANSAS If You have a question concerning Your coverage or a claim, first contact the Employer or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Employer and MetLife, You should feel free to contact: Arkansas Insurance Department Consumer Services Division 1200 West Third Street Little Rock, Arkansas 72201 (501) 371-2640 or (800) 852-5494

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NOTICE FOR RESIDENTS OF CALIFORNIA IMPORTANT NOTICE TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE EMPLOYER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS YOU RECEIVE AFTER FILING A CLAIM. IF, AFTER CONTACTING THE EMPLOYER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA INSURANCE DEPARTMENT AT: DEPARTMENT OF INSURANCE 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 1 (800) 927-4357

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NOTICE FOR RESIDENTS OF THE STATE OF CALIFORNIA California law provides that for vision insurance, domestic partners of California’s residents must be treated the same as spouses. If the certificate does not already have a definition of domestic partner, then the following definition applies: “Domestic Partner means each of two people, one of whom is an employee of the Employer, a resident of California and who have registered as domestic partners or members of a civil union with the California or another government recognized by California as having similar requirements.

For purposes of determining who may become a Covered Person, the term does not include any person who: · ·

is in the military of any country or subdivision of a country; is insured under the Group Policy as an employee.”

If the certificate already has a definition of domestic partner, that definition will apply to California residents, as long as it recognizes as a domestic partner any person registered as the employee’s domestic partner with the California government or another government recognized by California as having similar requirements.

Wherever the term Spouse appears, except in the definition of Spouse, it shall be replaced by Spouse or Domestic Partner.

Wherever the term step-child appears, it is replaced by step-child or child of Your Domestic Partner.

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NOTICE FOR RESIDENTS OF GEORGIA IMPORTANT NOTICE The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence.

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NOTICE FOR RESIDENTS OF IDAHO If You have a question concerning Your coverage or a claim, first contact the Employer. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Employer and MetLife, You should feel free to contact: Idaho Department of Insurance Consumer Affairs 700 West State Street, 3rd Floor PO Box 83720 Boise, Idaho 83720-0043 1-800-721-3272 (for calls placed within Idaho) or 208-334-4250 or www.DOI.Idaho.gov

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NOTICE FOR RESIDENTS OF ILLINOIS IMPORTANT NOTICE To make a complaint to MetLife, You may write to: MetLife P.O. Box 997100 Sacramento, CA 95899-7100 The address of the Illinois Department of Insurance is: Illinois Department of Insurance Public Services Division Springfield, Illinois 62767

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NOTICE FOR RESIDENTS OF INDIANA Questions regarding your policy or coverage should be directed to: Metropolitan Life Insurance Company 1-855-METEYE1 If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204 Consumer Hotline: (800) 622-4461; (317) 232-2395 Complaint can be filed electronically at www.in.gov/idoi

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NOTICE FOR RESIDENTS OF MAINE You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a default on Your part, such as nonpayment of a contribution that is due. The intent is to allow reinstatements where the default is due to the insured personâ&#x20AC;&#x2122;s suffering from cognitive impairment or functional incapacity.

You may make this designation by completing a "Third-Party Notice Request Form" and sending it to MetLife.

Once You have made a designation, You may cancel or change it by filling out a new Third-Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date MetLife receives the form. Call MetLife at the toll-free telephone number shown on the face page of this certificate to obtain a Third-Party Notice Request Form. Within 90 days after cancellation of coverage for nonpayment of premium, You, any person authorized to act on Your behalf, or any covered Dependent may request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional incapacity at the time of cancellation.

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NOTICE FOR RESIDENTS OF MASSACHUSETTS CONTINUATION OF VISION INSURANCE 1. If Your Vision Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be continued for 90 days after the date it ends.

2. If Your Vision Insurance ends because: · ·

You cease to be in an Eligible Class; or Your employment terminates;

for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days after the date it ends.

Continuation of Your Vision Insurance under the CONTINUATION WITH PREMIUM PAYMENT subsection will end before the end of continuation periods shown above if You become covered for similar benefits under another plan.

Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws, Chapter 151A, Section 71A. CONTINUATION OF VISION INSURANCE FOR YOUR FORMER SPOUSE If the judgment of divorce dissolving Your marriage provides for continuation of insurance for Your former Spouse when You remarry, Vision Insurance for Your former Spouse that would otherwise end may be continued.

To continue Vision insurance under this provision: 1. You must make a written request to the employer to continue such insurance; 2. You must make any required premium to the employer for the cost of such insurance.

The request form will be furnished by the Employer.

Such insurance may be continued from the date Your marriage is dissolved until the earliest of the following: ·

the date Your former Spouse remarries;

·

the date of expiration of the period of time specified in the divorce judgment during which You are required to provide Vision Insurance for Your former Spouse;

·

the date coverage is provided under any other group health plan;

·

the date Your former Spouse becomes entitled to Medicare;

·

the date Vision Insurance under the policy ends for all active employees, or for the class of active employees to which You belonged before Your employment terminated;

·

the date of expiration of the last period for which the required premium payment was made; or

·

the date such insurance would otherwise terminate under the policy.

If Your former Spouse is eligible to continue Vision Insurance under this provision and any other provision of this Policy, all such continuation periods will be deemed to run concurrently with each other and shall not be deemed to run consecutively.

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NOTICE FOR NEW HAMPSHIRE RESIDENTS CONTINUATION OF YOUR VISION INSURANCE If You are a resident of New Hampshire, Your Vision Insurance may be continued if it ends because Your employment ends unless: ·

Your employment ends due to Your gross misconduct;

·

this Vision Insurance ends for all employees;

·

this Vision Insurance is changed to end Vision Insurance for the class of employees to which You belong;

·

You are entitled to enroll in Medicare; or

·

Your Vision Insurance ends because You failed to pay the required premium.

The Employer must give You written notice of: ·

Your right to continue Your Vision Insurance;

·

the amount of premium payment that is required to continue Your Vision Insurance;

·

the manner in which You must request to continue Your Vision Insurance and pay premiums; and

·

the date by which premium payments will be due.

The premium that You must pay for Your continued Vision Insurance may include: ·

any amount that You contributed for Your Vision Insurance before it ended;

·

any amount the Employer paid; and

·

an administrative charge which will not to exceed two percent of the rest of the premium.

To continue Your Vision Insurance, You must: ·

send a written request to continue Your Vision Insurance; and

·

pay the first premium within 30 days after the date Your employment ends.

The maximum continuation period will be the longest of: ·

36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;

·

29 months if You become entitled to disability benefits under Social Security within 60 days of the date Your Employment ends; or 18 months.

·

Your continued Vision Insurance will end on the earliest of the following to occur: ·

the end of the maximum continuation period;

·

the date this Vision Insurance ends;

·

the date this Vision Insurance is changed to end Vision Insurance for the class of employees to which You belong;

·

the date You are entitled to enroll for Medicare;

·

if You do not pay the required premium to continue Your Vision Insurance; or

·

the date You become eligible for coverage under any other group vision coverage.

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NOTICE FOR NEW HAMPSHIRE RESIDENTS (continued) CONTINUATION OF YOUR DEPENDENT’S VISION INSURANCE If You are a resident of New Hampshire, Your Vision Insurance for Your Dependents may be continued if it ends because Your employment ends, Your marriage ends in divorce or separation, or You die, unless: ·

Your employment ends due to Your gross misconduct;

·

this Vision Insurance ends for all Dependents;

·

this Vision Insurance is changed, for the class of employees to which You belong, to end Vision Insurance for Dependents;

·

the Dependent is entitled to enroll in Medicare; or

·

Your Vision Insurance for Your Dependents ends because You fail to pay a required premium.

If Vision Insurance for Your Dependents ends because Your marriage ends in divorce or separation, the party responsible under the divorce decree or separation agreement for payment of premium for continued Vision Insurance must notify the employer, in writing, within 30 days of the date of the divorce decree or separation agreement that the divorce or separation has occurred. If You and Your divorced or separated Spouse share responsibility for payment of the premium for continued Vision Insurance, both You and Your divorced or separated Spouse must provide the notification.

The Employer must give You, or Your former Spouse if You have died or Your marriage has ended, written notice of: ·

Your right to continue Your Vision Insurance for Your Dependents;

·

the amount of premium payment that is required to continue Your Vision Insurance for Your Dependents;

·

the manner in which You or Your former Spouse must request to continue Your Vision Insurance for Your Dependents and pay premiums; and

·

the date by which premium payments will be due.

The premium that You or Your former Spouse must pay for continued Vision Insurance for Your Dependents may include: ·

any amount that You contributed for Your Vision Insurance before it ended; and

·

any amount the Employer paid.

To continue Vision Insurance for Your Dependents, You or Your former Spouse must: ·

send a written request to continue Vision Insurance for Your Dependents; and

·

must pay the first premium within 30 days of the date Vision Insurance for Your Dependents ends.

If You, and Your former Spouse, if applicable, fail to provide any required notification, or fail to request to continue Vision Insurance for Your Dependents and pay the first premium within the time limits stated in this section, Your right to continue Vision Insurance for Your Dependents will end.

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NOTICE FOR NEW HAMPSHIRE RESIDENTS (continued) CONTINUATION OF YOUR DEPENDENT’S VISION INSURANCE (continued) The maximum continuation period will be the longest of the following that applies: ·

36 months if Vision Insurance for Your Dependents ends because Your marriage ends in divorce or separation, except that with respect to a Spouse who is age 55 or older when your marriage ends in divorce or separation the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group plan;

·

36 months if Vision Insurance for Your Dependents ends because You die, except that with respect to a Spouse who is age 55 or older when You die, the maximum continuation period will end when Your surviving Spouse becomes eligible for Medicare or eligible for participation in another employer’s group vision coverage;

·

36 months if Vision Insurance for Your Dependents ends because You become entitled to benefits under Title XVIII of Social Security, except that with respect to a Spouse who is age 55 or older when You become entitled to benefits under Title XVIII of Social Security, the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group vision coverage;

·

36 months if You become entitled to benefits under Title XVIII of Social Security while You are already receiving continued benefits under this section, except that with respect to a Spouse who is age 55 or older when You first become entitled to continue Your Vision Insurance the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer’s group vision coverage;

·

36 months with respect to a Dependent Child if Vision Insurance ends because the Child ceases to be a Dependent Child;

·

36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code;

·

29 months if Vision Insurance for Your Dependents ends because Your employment ends, and within 60 days of the date Your employment ends you become entitled to disability benefits under Social Security; or

·

18 months if Vision Insurance for Your Dependents ends because Your employment ends.

A Dependent's continued Vision Insurance will end on the earliest of the following to occur: ·

the end of the maximum continuation period;

·

the date this Vision Insurance ends;

·

the date this Vision Insurance is changed to end Vision Insurance for Dependents for the class of employees to which You belong;

·

the date the Dependent becomes entitled to enroll for Medicare;

·

if You do not pay a required premium to continue Vision Insurance for Your Dependents; or

·

the date the Dependent becomes eligible for coverage under any other group vision coverage.

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NOTICE FOR RESIDENTS OF NORTH CAROLINA UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER, PRINCIPAL, AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE PAYMENT OF GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS, SHALL: (1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE INSURANCE, HOSPITAL, MEDICAL, OR DENTAL SERVICE CORPORATION PLAN, MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN COVERAGES AND THE CONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSONS INSURED, BY WILLFULLY FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE WITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT, AND (2) WILLFULLY FAIL TO DELIVER, AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE COVERAGES, TO ALL PERSONS COVERED BY THE GROUP POLICY A WRITTEN NOTICE OF THE PERSON'S INTENTION TO STOP PAYMENT OF PREMIUMS. THIS WRITTEN NOTICE MUST ALSO CONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP POLICY OF THEIR RIGHTS TO HEALTH INSURANCE CONVERSION POLICIES UNDER ARTICLE 53 OF CHAPTER 58 OF THE GENERAL STATUTES AND THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THE FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE 68 OF CHAPTER 58 OF THE GENERAL STATUTES. VIOLATION OF THIS LAW IS A FELONY. ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECT TO A COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOR EXPENSES OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE.

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NOTICE FOR RESIDENTS OF PENNSYLVANIA Vision Insurance for a Dependent Child may be continued past the age limit if that Child is a full-time student and insurance ends due to the Child being ordered to active duty (other than active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the United States.

Insurance will continue if such Child: · · · ·

re-enrolls as a full-time student at an accredited school, college or university that is licensed in the jurisdiction where it is located; re-enrolls for the first term or semester, beginning 60 or more days from the child’s release from active duty; continues to qualify as a Child, except for the age limit; and submits the required Proof of the child’s active duty in the National Guard or a Reserve Component of the United States Armed Forces.

Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of the date: · ·

the insurance has been continued for a period of time equal to the duration of the child’s service on active duty; or the child is no longer a full-time student.

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NOTICE FOR RESIDENTS OF UTAH Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Utah law, which determines who and what is covered and the amounts of coverage.

The Association was established to provide protection in the unlikely event that your life, health, or annuity insurance company becomes financially unable to meet its obligations and is taken over by its insurance regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other insurance companies.

The basic protections provided by the Association are: · Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values · Health Insurance o $500,000 in hospital, medical and surgical insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in disability income insurance benefits o $500,000 in other types of health insurance benefits · Annuities o $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits.

Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract.

Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a complete description of coverage, consult Utah Code, Title 3 lA, Chapter 28.

Insurance companies and agents are prohibited by Utah law to use the existence of the Association or its coverage to encourage you to purchase insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between Utah law and this notice, Utah law will control.

To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.utlifega.org or contact: Utah Life and Health Insurance Guaranty Assoc.

60 East South Temple, Suite 500 Salt Lake City UT 84111 (801) 320-9955

Utah Insurance Department 3110 State Office Building Salt Lake City UT 84114-6901 (801) 538-3800

A written complaint about misuse of this Notice or the improper use of the existence of the Association may be filed with the Utah Insurance Department at the above address.

GTY-NOTICE-UT-0710

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NOTICE FOR RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have additional questions You may contact the insurance company issuing this insurance at the following address and telephone number: MetLife P.O. Box 997100 Sacramento, CA 95899-7100 Attn: Corporate Consumer Relations Department To phone in a claim related question, You may call Claims Customer Service at: 1-855-METEYE1 If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the Virginia State Corporation Commission’s Bureau of Insurance at: The Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA 23209 1-877-310-6560 - toll-free 1-804-371-9944 - locally www.scc.virginia.gov - web address ombudsman@scc.virginia.gov - email Or: Office of Licensure and Certification Division of Acute Care Services Virginia Department of Health 9960 Mayland Drive Suite 401 Henrico, Virginia 23233-1463 Phone number: 1-800-955-1819/ local: 804-367-2106 Fax: (804) 527-4503 MCHIP@vdh.virginia.gov Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your agent, company or the Bureau of Insurance, have Your policy number available.

VISION INSURANCE: PROCEDURES FOR VISION CLAIMS Routine Questions on Vision Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1855-METEYE1.

Claim Denial Appeals If a claim is denied in whole or in part, under the terms of this certificate, a request may be submitted to Us by a Covered Person or a Covered Person’s authorized representative for a full review of the denial. A Covered Person may designate any person, including their provider, as their authorized representative. References in this section to “Covered Person” include the Covered Person’s authorized representative, where applicable.

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NOTICE FOR RESIDENTS OF VIRGINIA (continued) Initial Appeal. All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. A Covered Person may review, during normal business hours, any documents used by Us pertinent to the denial. A Covered Person may also submit Written comments or supporting documentation concerning the claim to assist in Our review. Our response to the initial appeal, including specific reasons for the decision, shall be communicated to the Covered Person within thirty (30) calendar days after receipt of the request for the appeal.

Second Level Appeal. If a Covered Person disagrees with the response to the initial appeal of the denied claim, the Covered Person has the right to a second level appeal. A request for a second level appeal must be submitted to Us within sixty (60) calendar days after receipt of Our response to the initial appeal. We shall communicate Our final determination to the Covered Person within thirty (30) calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations. Our communication to the Covered Person shall include the specific reasons for the determination.

Other Remedies. When a Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation or arbitration. Additional information is available from the U.S. Department of Labor or the insurance regulatory agency for the Covered Personsâ&#x20AC;&#x2122; state of residency. Additionally, under the provisions of ERISA (Section 502(a)(1)(B) 29 U.S.C. 1132(a)(1)(B)), the Covered Person has the right to bring a civil action when all available levels of reviews, including the appeal process, have been completed. ERISA remedies may apply in those instances where the claims were not approved in whole or in part as the result of appeals under this Policy and the Covered Person disagrees with the outcome of such appeals.

Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the Covered Person exhausting his/her rights under this Policy and/or prior to the expiration of sixty (60) calendar days after the claim and any applicable documentation has been filed with Us. No such action shall be brought after the expiration of any applicable statute of limitations, in accordance with the terms of this Policy. No such action shall be brought after the expiration of three (3) years from the last date that the claim and any applicable invoices were submitted to Us, and no such action shall be brought at all unless brought within three (3) years from the expiration of the time within which such materials are required to be submitted in accordance with the terms of this Policy.

Insurance Fraud: Any Covered Person who intends to defraud, knowingly facilitates a fraud, submits a claim containing false or deceptive information, or who commits any other similar act as defined by applicable state or federal law, is guilty of insurance fraud. Such an act is grounds for immediate termination of the coverage under this Policy of the Covered Person committing such fraud.

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NOTICE FOR RESIDENTS OF WISCONSIN

KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS

PROBLEMS WITH YOUR INSURANCE? - If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.

MetLife Attn: Corporate Consumer Relations Department P.O. Box 997100 Sacramento, CA 95899-7100 1-800-638-5433

You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsinâ&#x20AC;&#x2122;s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting:

Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1-800-236-8517 outside of Madison or 608-266-0103 in Madison.

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NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW HAMPSHIRE, NEW MEXICO, UTAH AND WASHINGTON The Definition of Child In The Definitions Section Of This Certificate Is Modified For The Coverage Listed Below: For Alaska Residents (Vision Insurance): The term also includes newborns.

For Louisiana Residents (Vision Insurance): The term also includes Your grandchildren residing with You. The age limit for children and grandchildren will not be less than 21, regardless of the child’s or grandchild’s student status or full-time employment status. In addition, the age limit for students will not be less than 24. Your natural child, adopted child, stepchild or grandchild under age 21 will not need to be supported by You to qualify as a Child under this insurance.

For Minnesota Residents (Vision Insurance): The term also includes · · ·

Your grandchildren who are financially dependent upon You and reside with You continuously from birth; children for whom You or Your Spouse is the legally appointed guardian; and children for whom You have initiated for adoption.

The age limit for children and grandchildren will not be less than 25, regardless of the child’s or grandchild’s student status or full-time employment status. Your natural child, adopted child, stepchild, or children for whom You or Your Spouse is the legally appointed guardian under age 25 will not need to be supported by You to qualify as a Child under this insurance.

For Montana Residents (Vision Insurance): The term also includes newborn infants of any person insured under this certificate. The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a child under this insurance.

For New Hampshire Residents (Vision Insurance): The age limit for children will not be less than 26, regardless of the child’s marital, student status or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported

by You to qualify as a child under this insurance.

For New Mexico Residents (Vision Insurance): The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild will not be denied vision insurance coverage under this certificate because: · · ·

that child was born out of wedlock; that child is not claimed as Your dependent on Your federal income tax return; or that child does not reside with You.

For Utah Residents (Vision Insurance): The age limit for children will not be less than 26, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported

by You to qualify as a Child under this insurance.

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NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW HAMPSHIRE, NEW MEXICO, UTAH AND WASHINGTON For Washington Residents (Vision Insurance): The age limit for children will not be less than 26, regardless of the childâ&#x20AC;&#x2122;s marital status, student status, or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance.

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NOTICE FOR RESIDENTS OF ALL STATES WHO ARE INSURED FOR VISION INSURANCE Notice Regarding Your Rights and Responsibilities Rights: ·

We will treat communications, financial records and records pertaining to your care in accordance with all applicable laws relating to privacy.

·

Decisions with respect to vision treatment are the responsibility of You and the Vision Provider. We neither require nor prohibit any specified treatment. However, only certain specified services are covered for benefits. Please see the Vision Insurance sections of this certificate for more details.

·

You may request a written response from MetLife to any written concern or complaint.

Responsibilities: ·

You are responsible for the prompt payment of any charges for services performed by the Vision Provider not fully covered by your Vision Insurance.

·

You should consult with the Vision Provider about treatment options, proposed and potential procedures, anticipated outcomes, potential risks, anticipated benefits and alternatives. You should share with the Vision Provider the most current, complete and accurate information about your medical and vision history and current conditions and medications.

·

You should follow the treatment plans and health care recommendations agreed upon by You and the Vision Provider.

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TABLE OF CONTENTS Section

Page

CERTIFICATE FACE PAGE............................................................................................................................... 1 NOTICES............................................................................................................................................................ 2 SCHEDULE OF BENEFITS.............................................................................................................................. 27 DEFINITIONS.................................................................................................................................................... 30 ELIGIBILITY PROVISIONS: INSURANCE FOR YOU...................................................................................... 33 Eligible Classes........................................................................................................................................... 33 Date You Are Eligible For Insurance...........................................................................................................33 Enrollment Process For Vision Insurance................................................................................................... 33 Date Your Insurance Takes Effect.............................................................................................................. 33 Date Your Insurance Ends.......................................................................................................................... 34 ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS.......................................................... 35 Eligible Classes For Dependent Insurance................................................................................................. 35 Date You Are Eligible For Dependent Insurance........................................................................................ 35 Enrollment Process For Dependent Vision Insurance................................................................................ 35 Date Your Insurance Takes Effect For Your Dependents...........................................................................35 Date Your Insurance For Your Dependents Ends...................................................................................... 36 CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.................................................................... 38 For Mentally or Physically Handicapped Children...................................................................................... 38 For Family And Medical Leave................................................................................................................... 38 COBRA Continuation For Vision Insurance................................................................................................ 38 At The Employer's Option........................................................................................................................... 38 VISION INSURANCE........................................................................................................................................ 39 VISION INSURANCE: DESCRIPTION OF COVERED SERVICES AND MATERIALS................................... 41 VISION INSURANCE: EXCLUSIONS............................................................................................................... 42 GCERT2000 toc

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TABLE OF CONTENTS (continued) VISION INSURANCE: COORDINATION OF BENEFITS................................................................................. 43 VISION INSURANCE: FILING A CLAIM........................................................................................................... 47 VISION INSURANCE: PROCEDURES FOR VISION CLAIMS........................................................................ 48 GENERAL PROVISIONS.................................................................................................................................. 49 Assignment................................................................................................................................................. 49 Vision Insurance: Who We Will Pay............................................................................................................49 Entire Contract............................................................................................................................................ 49 Incontestability: Statements Made By By You............................................................................................ 49 Conformity With Law................................................................................................................................... 49

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SCHEDULE OF BENEFITS This schedule shows the benefits that are available under the Group Policy. You and Your Dependents will only be insured for the benefits: · · ·

for which You and Your Dependents become and remain eligible; which You elect, if subject to election; and which are in effect.

BENEFIT

BENEFIT AMOUNTS AND HIGHLIGHTS

Vision Insurance For You and Your Dependents For All Active Full-Time Employees Service Interval (months)

Exam 12 months

Lenses 12 months

Frame 24 months

Exam In-Network Co-Pay Co-payment shall not apply to Retinal Imaging

$10

Materials In-Network Co-Pay Co-payment shall not apply to Elective Contact Lenses

$25

In-Network Coverage (Using an In-Network Vision Provider)

EYE EXAMINATION

Contacts 12 months

Out-of-Network Coverage (Using an Out-of-Network Vision Provider)

Covered in full*

Covered up to $45 allowance

(one per frequency)

Comprehensive examination of visual functions and prescription of corrective eyewear.

Comprehensive examination of visual functions and prescription of corrective eyewear.

RETINAL IMAGING

Covered in full with a co-pay not to exceed $39.

Applied to the allowance for the eye examination

Coverage for retinal imaging is an enhancement to eye examination.

Retinal imaging is not available at all provider locations – contact your InNetwork Vision Provider to see if this technology (or equipment or service) is available.

STANDARD CORRECTIVE LENSES

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Single Vision Covered in full*

Covered up to $30 allowance

Lined Bifocal Covered in full*

Covered up to $50 allowance

Lined Trifocal Covered in full*

Covered up to $65 allowance

Lenticular Covered in full*

Covered up to $100 allowance

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SCHEDULE OF BENEFITS (continued) STANDARD LENS OPTIONS1

Ultra Violet Coating Covered in full*

Polycarbonate (child up to age 18) Covered in full*

Standard or Premium Progressive Available at a discount

Applied to the allowance for the applicable corrective lens

Applied to the allowance for the applicable corrective lens Standard Progressive $50 allowance; or Premium Progressive $50 allowance

Polycarbonate (adult) Available at a discount

Scratch Resistant Coating Available at a discount

Tints Available at a discount

Anti-Reflective Coating Available at a discount

Photochromic Available at a discount

FRAMES

Covered up to a $130 allowance

Applied to the allowance for the applicable corrective lens

Applied to the allowance for the applicable corrective lens

Applied to the allowance for the applicable corrective lens

Applied to the allowance for the applicable corrective lens

Applied to the allowance for the applicable corrective lens

Covered up to a $70 allowance

Frames are covered to the allowance of $70* at Costco locations.

In-Network Vision Providers prescribe and/or order Covered Personâ&#x20AC;&#x2122;s lenses, verify the accuracy of finished lenses, and assist Covered Person with frame selection and adjustment.

Frames are covered up to the allowance of $70* at Costco and $130* at other optical retail locations.

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SCHEDULE OF BENEFITS (continued) CONTACT LENSES

In-Network Coverage (Using an In-Network Vision Provider)

FITTING AND EVALUATION

Standard and Premium fit:

Out-of-Network Coverage (Using an Out-of-Network Vision Provider)

Covered in full with a co-pay not to exceed $60.

Applied to the allowance for the contact lenses

ELECTIVE

Covered up to $130 allowance Contact lenses are provided in place of lens and frame benefits available herein.

Covered up to $105 allowance Contact lenses are provided in place of lens and frame benefits available herein.

NECESSARY

Covered in full*

Covered up to $210 allowance

Necessary contact lenses are a Plan Benefit when specific criteria are satisfied and when prescribed by Covered Person’s In-Network Vision Provider.

Necessary contact lenses are a Plan Benefit when specific criteria are satisfied and when prescribed by Covered Person’s In-Network Vision Provider.

Contact lenses are provided in place of lens and frame benefits available herein.

Contact lenses are provided in place of lens and frame benefits available herein.

* Less any applicable Co-payment.

1

All lens enhancements are available at participating private practice provider offices, and not to exceed copays and pricing are subject to change without notice. Please check with your provider for details and copays applicable to your lens choice. At this time, all lens enhancements and “not to exceed” copays and pricing are not available at Costco. Please contact your local Costco to confirm the availability of lens enhancements and pricing prior to receiving services.

Value-Added Features Available At In-Network Vision Providers (These features are not insurance.)

LASER VISION CORRECTION Savings averaging 15% off the regular price, or 5% off a promotional offer, for laser surgery including PRK, LASIK, and Custom LASIK. ADDITIONAL SAVINGS ON 20% savings on additional pairs of prescription glasses and GLASSES AND SUNGLASSES nonprescription sunglasses, including lens enhancements.2 At times, other promotional offers may also be available.

ADDITIONAL SAVINGS ON LENS Average 20-25% savings on all lens enhancements not otherwise ENHANCEMENTS covered under the MetLife Vision Insurance program. 2 2

These features may not be available in all states and with all In-Network Vision Providers. Please check with Your In-Network Vision Provider.

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DEFINITIONS As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning.

Actively at Work or Active Work means that You are performing all of the usual and customary duties of Your job on a Full-Time basis. This must be done at: · · ·

the Employer's place of business; an alternate place approved by the Employer; or a location to which the Employer's business requires You to travel.

You will be deemed to be Actively at Work during weekends or Employer-approved vacations, holidays or business closures if You were Actively at Work on the last scheduled work day preceding such time off.

Anisometropia means a condition of unequal refractive state of the two eyes, one eye requiring a different lens correction than the other.

Child means the following: (for residents of Louisiana, Minnesota, Montana, New Hampshire, New Mexico, Utah and Washington, the Child Definition is modified as explained in the Notice pages of this certificate please consult the Notice) For Vision Insurance, Your natural or adopted child; Your stepchild (including the child of a Domestic Partner); or a child who resides with and is fully supported by You; and who, in each case, is under age 26. The term also includes Your grandchild who is under age 26, and who was able to be claimed by You as a Dependent for Federal Income Tax purposes at the time You applied for Vision Insurance.

A child will be considered Your adopted child during the period You are party to a suit in which You are seeking the adoption of the child.

If You provide Us notice, a Child also includes a child for whom You must provide Vision Insurance due to a Qualified Medical Child Support Order as defined in the United States Employee Retirement Income Security Act of 1974 as amended.

For the purposes of determining who may become covered for insurance, the term does not include any person who: ·

·

is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or is insured under the Group Policy as an employee.

Contributory Insurance means insurance for which the Employer requires You to pay any part of the premium.

Contributory Insurance includes: Vision Insurance for You and Your Dependents.

Co-Payment or Co-Pay means a fixed dollar amount for which We are not responsible, as shown in the Schedule of Benefits. You must pay Your Co-Payment at the time services are rendered or materials ordered.

Covered Person(s) means an Employee and/or a Dependent covered under this Certificate.

Covered Services and Materials means a vision service or materials used to treat Your or Your Dependent’s vision condition which is: · · ·

prescribed or performed by a Vision Provider while such person is insured for Vision Insurance; Necessary to treat the condition; and described in the SCHEDULE OF BENEFITS, VISION INSURANCE or VISION INSURANCE: DESCRIPTION OF COVERED SERVICES AND MATERIALS sections of this certificate.

Dependent(s) means Your Spouse and/or Child.

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DEFINITIONS (continued) Domestic Partner means each of two people, one of whom is an employee of the Employer, who: ·

have registered as each other's domestic partner, civil union partner or reciprocal beneficiary with a government agency where such registration is available; or

·

are of the same or opposite sex and have a mutually dependent relationship so that each has an insurable interest in the life of the other. Each person must be: 1.

2.

3.

4.

5.

18 years of age or older; unmarried; the sole domestic partner of the other; sharing a primary residence with the other; and not related to the other in a manner that would bar their marriage in the jurisdiction in which they reside.

A Domestic Partner declaration attesting to the existence of an insurable interest in one another's lives must be completed and Signed by the employee.

Full-Time means Active Work on the Employer's regular work schedule for the class of employees to which You belong. The work schedule must be at least 30 hours a week. Full-Time does not include temporary or seasonal employees.

In-Network Vision Provider means an optometrist, therapeutic optometrist, ophthalmologist, or optician licensed and otherwise qualified to practice vision care and/or provide vision care materials who is contracted to provide Plan Benefits to Covered Persons of MetLife and accepts reimbursement at the negotiated rate.

Keratoconus means a development or dystrophic deformity of the cornea in which it becomes cone shaped due to a thinning and stretching of the tissue in its central area.

Maximum Benefit Allowance means the maximum amount We will allow for Covered Services and Materials provided by a Vision Provider.

Necessary means Covered Services and Materials that are necessary and meet with professionally recognized standards of practice. The fact that a Vision Provider may prescribe, order, recommend or approve a service or material does not, in itself, make it medically necessary, or make it a Covered Service and Material even though it is listed in the Group Policy or the Benefit Schedule as Covered Service and Material.

Noncontributory Insurance means insurance for which the Employer does not require You to pay any part of the premium.

Out-of-Network Vision Provider/Non-Network Vision Provider means any optometrist, therapeutic optometrist, optician, ophthalmologist or other licensed and qualified vision care provider who has not contracted to provide vision care services and/or vision care materials to Covered Persons of MetLife.

Plan or Plan Benefits means the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under this Certificate.

Progressive Lens means a multifocal lens that makes the transition from distance to near vision by a gradual, progressive addition of power. The result is a lens with a seamless appearance.

Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish: · · ·

the nature and extent of the loss or condition; Our obligation to pay the claim; and the claimant’s right to receive payment.

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DEFINITIONS (continued) Proof must be provided at the claimant’s expense.

Service Interval or Frequency means a period of consecutive months, as shown in the SCHEDULE OF BENEFITS, in which You or Your Dependent may receive Covered Services and Materials. This period starts on Your or Your Dependent’s effective date of coverage. A subsequent service interval starts after vision services or materials are received. Once Covered Services and Materials are received during any service interval, additional services are not covered during the same service interval and are subject to an additional charge.

Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

Spouse means Your lawful Spouse. Wherever the term "Spouse" appears in the certificate it shall, unless otherwise specified, be read to include Your Domestic Partner.

For the purposes of determining who may become covered for insurance, the term does not include any person who: ·

is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or

·

is insured under the Group Policy as an employee.

Vision Provider means an eye care professional who is an optometrist, therapeutic optometrist, ophthalmologist, or registered dispensing optician, who: · ·

is licensed as such by the proper authorities in the jurisdiction where such services are performed; is acting within the scope of such license; and

The term does not include: · · ·

You; Your Spouse; or any member of Your immediate family including Your and/or Your Spouse’s: · parents; · children (natural, step or adopted); · siblings; · grandparents; or · grandchildren.

We, Us and Our mean MetLife.

Written or Writing means a record which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law.

Year or Yearly means the 12 month period that begins January 1.

You and Your mean an employee who is insured under the Group Policy for the insurance described in this certificate.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ELIGIBLE CLASS(ES) All Active Full-Time Employees DATE YOU ARE ELIGIBLE FOR INSURANCE You may only become eligible for the insurance available for Your class as shown in the SCHEDULE OF BENEFITS. For All Active Full-Time Employees You will be eligible for insurance on the later of: 1. January 1, 2017; and 2. the first day of the month coincident with or next following the date You enter that class.

Waiting Period means the period of continuous membership in an eligible class that You must wait before You become eligible for insurance. This period begins on the date You enter an eligible class and ends on the date You complete the period(s) specified.

ENROLLMENT PROCESS FOR VISION INSURANCE If You are eligible for insurance, You may enroll for such insurance by completing the required form in Writing.

If You enroll for Contributory Insurance, You must also give the Employer Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Employer how much You will be required to contribute.

The Vision Insurance has a regular enrollment period established by the Employer. Subject to the rules of the Group Policy, You may enroll for Vision Insurance only when You are first eligible or during an annual enrollment period or if You have a Qualifying Event. You should contact the Employer for more information regarding the annual enrollment period.

DATE YOUR INSURANCE TAKES EFFECT Enrollment When First Eligible If You complete the enrollment process within 31 days of becoming eligible for insurance, such insurance will take effect on the date You become eligible, provided You are Actively at Work on that date.

If You are not Actively at Work on the date the insurance would otherwise take effect, the benefit will take effect on the day You resume Active Work.

If You Do Not Enroll When First Eligible If You do not complete the enrollment process within 31 days of becoming eligible, You will not be able to enroll for Vision Insurance until the next annual enrollment period, as determined by the Employer, following the date You first become eligible or if You have a Qualifying Event. At that time You will be able to enroll for insurance for which You are then eligible.

Enrollment During An Annual Enrollment Period During any annual enrollment period as determined by the Employer, You may enroll for vision insurance for which You are eligible. The changes to Your insurance made during an annual enrollment period will take effect on the first day of the month following the enrollment period, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU Enrollment Due to a Qualifying Event You may enroll for insurance for which You are eligible between annual enrollment periods only if You have a Qualifying Event.

If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or changes to Your insurance made as a result of a Qualifying Event will take effect on the date of the Qualifying Event, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Qualifying Event includes: ·

marriage; or

·

the birth, adoption or placement for adoption of a dependent child; or

·

divorce, legal separation or annulment; or

·

the death of a dependent; or

·

You previously did not enroll for vision coverage for You or Your dependent because You had other group coverage, but that coverage has ceased due to loss of eligibility for the other group coverage; or

·

Your dependent's ceasing to qualify as a dependent under this insurance or under other group coverage.

DATE YOUR INSURANCE ENDS Your insurance will end on the earliest of: 1. the date the Group Policy ends; 2. the date insurance ends for Your class; 3. the end of the period for which the last premium has been paid for You; 4. the last day of the calendar month in which Your employment ends; Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; 5. the last day of the calendar month in which You retire in accordance with the Employer’s retirement plan.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS ELIGIBLE CLASS(ES) All Active Full-Time Employees DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE You may only become eligible for the Dependent insurance available for Your class as shown in the SCHEDULE OF BENEFITS. For All Active Full-Time Employees You will be eligible for Dependent insurance on the later of: 1. January 1, 2017; and 2. the first day of the month coincident with or next following the date You enter that class.

Waiting Period means the period of continuous membership in an eligible class that You must wait before You become eligible for Dependent insurance. This period begins on the date You enter an eligible class and ends on the date You complete the period(s) specified.

No person may be insured as a Dependent of more than one employee.

ENROLLMENT PROCESS FOR DEPENDENT VISION INSURANCE If You are eligible for Dependent insurance, You may enroll for such insurance by completing the required form in Writing. If You enroll for Contributory Insurance, You must also give the Employer Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Employer how much You will be required to contribute.

In order to enroll for Vision Insurance for Your Dependents, You must either (a) already be enrolled for Vision Insurance for You or (b) enroll at the same time for Vision Insurance for You. The Vision Insurance has a regular enrollment period established by the Employer. Subject to the rules of the Group Policy, You may enroll for Vision Insurance only when You are first eligible or during an annual enrollment period or if You have a Qualifying Event. You should contact the Employer for more information regarding the annual enrollment period.

DATE YOUR INSURANCE TAKES EFFECT FOR YOUR DEPENDENTS Enrollment When First Eligible If You complete the enrollment process within 31 days of becoming eligible for Dependent Insurance, such insurance will take effect on the later of: ¡ ¡

the date You become eligible for such insurance; and the date You enroll

provided You are Actively at Work on that date. If You are not Actively at Work on the date the insurance would otherwise take effect, the benefit will take effect on the day You resume Active Work.

If You Do Not Enroll When First Eligible If You do not complete the enrollment process within 31 days of becoming eligible, You will not be able to enroll for Dependent Vision Insurance until the next annual enrollment period, as determined by the Employer, following the date You first become eligible or if You have a Qualifying Event. At that time You will be able to enroll for insurance for which You are then eligible.

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) Enrollment During An Annual Enrollment Period During any annual enrollment period as determined by the Employer, You may enroll for Dependent vision insurance for which You are eligible. The changes to Your Dependent insurance made during an annual enrollment period will take effect on the first day of the month following the enrollment period, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Enrollment Due to a Qualifying Event You may enroll for Dependent insurance for which You are eligible between annual enrollment periods only if You have a Qualifying Event.

If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or changes to Your insurance made as a result of a Qualifying Event will take effect on the date of the Qualifying Event, if You are Actively at Work on that date.

If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the day You resume Active Work.

Qualifying Event includes: ·

marriage; or

·

the birth, adoption or placement for adoption of a dependent child; or

·

divorce, legal separation or annulment; or

·

the death of a dependent; or

·

You previously did not enroll for vision coverage for You or Your dependent because You had other group coverage, but that coverage has ceased due to loss of eligibility for the other group coverage; or

·

Your dependent's ceasing to qualify as a dependent under this insurance or under other group coverage.

DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS A Dependent's insurance will end on the earliest of: 1. the date Your Vision Insurance ends; 2. the date You die; 3. the date the Group Policy ends; 4. the date Insurance for Your Dependents ends under the Group Policy; 5. the date Insurance for Your Dependents ends for Your class; 6. the last day of the calendar month in which Your employment ends; Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT. 7. the end of the period for which the last premium has been paid; 8. the date the person ceases to be a Dependent except in the case of a Dependent Child who has reached the maximum age as defined in the DEFINITIONS section, Insurance will end on the last day of the calendar month; 9. for Utah residents, the last day of the calendar month the person ceases to be a Dependent; 10. the last day of the calendar month in which You retire in accordance with the Employer's retirement plan.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF GCERT2000 e/dep

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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) INSURANCE WITH PREMIUM PAYMENT.

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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN Insurance for a Dependent Child may be continued past the age limit if the child is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of such handicap must be sent to Us within 31 days after the date the Child attains the age limit and at reasonable intervals after such date, but not more frequently than once a year after the two-year period following the child’s attainment of the limiting age.

Subject to the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue while such Child: ·

remains incapable of self-sustaining employment because of a mental or physical handicap; and

·

continues to qualify as a Child, except for the age limit.

FOR FAMILY AND MEDICAL LEAVE Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave Act of 1993 (FMLA), or other legally mandated leave of absence or similar laws. Please contact the Employer for information regarding such legally mandated leave of absence laws.

COBRA CONTINUATION FOR VISION INSURANCE The following applies to employers with 20 or more employees that are not church or government plans: If Vision Insurance for You or a Dependent ends, You or Your Dependent may qualify for continuation of such insurance under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA).

Please refer to the COBRA section of Your summary plan description or contact the Employer for information regarding continuation of insurance under COBRA. AT THE EMPLOYER’S OPTION The Employer has elected to continue insurance by paying premiums for employees who cease Active Work in an eligible class for any of the reasons specified below. If Your insurance is continued, insurance for Your Dependents may also be continued. You will be notified by the Employer how much You will be required to contribute.

Insurance will continue for the following periods: 1. for the period You cease Active Work in an eligible class due to layoff up to 2 months.

2. for the period You cease Active Work in an eligible class due to injury or sickness up to 9 months.

3. for the period You cease Active Work in an eligible class due to any other Employer approved leave of absence up to 2 months.

At the end of any of the continuation periods listed above, Your insurance will be affected as follows: ·

if You resume Active Work in an eligible class at this time, You will continue to be insured under the Group Policy;

·

if You do not resume Active Work in an eligible class at this time, Your employment will be considered to end and Your insurance will end in accordance with the DATE YOUR INSURANCE ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU.

If Your insurance ends, Your Dependents’ insurance will also end in accordance with the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS. GCERT2000 coi-eport

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VISION INSURANCE Benefits are available for Covered Services and Materials provided by either In-Network Vision Providers or Out-of-Network Vision Providers. However, You may be able to reduce Your out-of-pocket costs by using InNetwork Vision Providers because Out-of-Network Vision Providers have not entered into an agreement to limit their charges. You are always free to receive services from any Vision Provider. You do not need any authorization from Us before seeing a Vision Provider.

In-Network Vision Providers have agreed to provide Covered Services and Materials as listed in the SCHEDULE OF BENEFITS. If You or a Dependent incur a charge for Covered Services and Materials from an Out-of-Network Vision Provider, Proof of such service must be sent to Us. When We receive such Proof, We will review the claim and if We approve it, will pay the insurance in effect on the date that service was completed.

The benefits available under this Vision Insurance are set forth on the SCHEDULE OF BENEFITS. In addition to the Co-Payment, if applicable, You may be responsible for: · ·

the cost of any services or materials that are not Covered Services and Materials; and the cost of any service or material that is in excess of the Maximum Benefit Allowance listed on the SCHEDULE OF BENEFITS.

We do not provide vision services. Whether or not benefits are available for a particular service does not mean You should or should not receive the service. You and Your Vision Provider have the right and are responsible at all times for choosing the course of treatment and services to be performed.

When requesting Covered Services and Materials from an In-Network Vision Provider, We recommend that You confirm that the Vision Provider is currently an In-Network Vision Provider at the time that the Covered Services and Materials are provided.

You can obtain a customized listing of MetLife’s In-Network Vision Providers either by calling 1-855METEYE1 or by visiting Our website at www.metlife.com/mybenefits.

PLAN BENEFITS We will pay benefits for charges incurred by You or a Dependent for Covered Services and Materials as shown in the SCHEDULE OF BENEFITS, subject to the conditions set forth in this certificate.

If You receive Covered Services and Materials from an In-Network Vision Provider, We will pay the provider directly for all covered benefits.

If You or a Dependent receive Covered Services and Materials from an Out-of-Network Vision Provider, and You assign payment of Vision Insurance benefits to Your or Your Dependent's Vision Provider, We will pay benefits directly to the Vision Provider. Otherwise, We will pay Vision Insurance benefits to You. In-Network If Covered Services and Materials are provided by an In-Network Vision Provider, We will base the benefit on the Plan Benefits listed on the SCHEDULE OF BENEFITS. If an In-Network Vision Provider provides Covered Services and Materials, You will be responsible for paying: · ·

the Co-Payment, if applicable; and the cost of any service or material that is in excess of the Plan Benefits listed on the SCHEDULE OF BENEFITS.

Out-of-Network If Covered Services and Materials are provided by an Out-of-Network Vision Provider, We will base the benefit on the Plan Benefits listed on the SCHEDULE OF BENEFITS, subject to the Maximum Benefit Allowance.

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VISION INSURANCE (continued) Out-of-Network Vision Providers may charge You more than the Maximum Benefit Allowance. If an Out-ofNetwork Vision Provider provides Covered Services and Materials, You will be responsible for paying any amount in excess of the Maximum Benefit Allowance charged by the Out-of-Network Vision Provider.

Necessary Contact Lenses Necessary contact lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed

by Covered Person’s In-Network Vision Provider. Generally, coverage will be authorized for the following reasons: · · · · · · · ·

Aphakia—379.31 or 743.35.

Nystagmus—379.50 through 379.56, 386.11, 386.12 or 386.2.

Keratoconus—371.60, 371.61, 371.62, 743.41, or 743.42.

Corneal transplant—V42.5.

Corneal dystrophies—371.50 through 371.58.

Anisometropia greater than or equal to 2.00 diopters difference in any meridian based on the spectacle prescription.

High ametropia greater than or equal to ±10.00 diopters in either eye in any meridian based on the spectacle prescription.

Irregular astigmatism—367.22.

The codes listed above are from the International Classification of Diseases, Ninth Revision, Clinical Modification and are used to describe diseases, injuries, symptoms and conditions. If You have questions about the diagnoses listed above or the codes included with the diagnoses, please contact Your Vision Provider.

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VISION INSURANCE: DESCRIPTION OF COVERED SERVICES AND MATERIALS Subject to the Service Intervals and Plan Benefits indicated in the SCHEDULE OF BENEFITS, the following will be Covered Services and Materials: 1. One complete visual examination, if indicated as a Covered Service on the SCHEDULE OF BENEFITS. Dilation is included as a Covered Service when provided by an In-Network Vision Provider.

2. Standard corrective lenses. We will cover a pair of standard single vision, lined bifocal, lined trifocal or lenticular lenses that are necessary to correct vision. Standard corrective lenses are as follows: · · · · · ·

eyesizes up to and including 60mm; multi-focal lenses in all segment widths; prism and slab off; base curves (regardless of curve); lenses with the combined power in any meridian is +/- .50 diopters or greater in at least one eye; plastic or glass lenses.

3. The following lens options described in the SCHEDULE OF BENEFITS: tint (solid and gradient), standard plastic scratch coating, standard polycarbonate (if you are less than 18 years of age), standard antireflective coating, plastic photochromic, polarized premium anti-reflective.

4. Contact lenses. · ·

A standard fitting and 1 follow-up visit by a Vision Provider.

The following contact lenses options, as described in the SCHEDULE OF BENEFITS: conventional, disposable, and Necessary.

5. Necessary low vision aids.

6. We do not cover costs above the Maximum Benefit Allowance shown in the SCHEDULE OF BENEFITS for frames. If frames are selected that are more expensive than that amount, You will be charged the difference between the Maximum Benefit Allowance and the Vision Provider’s charge for the more expensive frame.

7. Necessary contact lenses in lieu of all benefits for vision materials.

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VISION INSURANCE: EXCLUSIONS We will not pay Vision Insurance benefits for charges incurred for: 1. Services and/or materials not specifically included in the SCHEDULE OF BENEFITS as covered Plan Benefits.

2. Any portion of a charge in excess of the Maximum Benefit Allowance or reimbursement indicated in the SCHEDULE OF BENEFITS. 3. Plano lenses (lenses with refractive correction of less than ± .50 diopter).

4. Two pairs of glasses instead of bifocals.

5. Replacement of lenses, frames and/or contact lenses furnished under this Plan which are lost, stolen or damaged, except at the normal intervals when Plan Benefits are otherwise available.

6. Orthoptics or vision training and any associated supplemental testing.

7. Medical or surgical treatment of the eye.

8. Prescription or non-prescription medications.

9. Contact lens insurance policies and service agreements.

10. Refitting of contact lenses after the initial (90-day) fitting period.

11. Contact lens modification, polishing and cleaning.

12. Any eye examination or any corrective eyewear required as a condition of employment.

13. Services or supplies received by You or Your Dependent before the Vision Insurance starts for that person.

14. Missed appointments.

15. Services or materials resulting from or in the course of a Covered Person’s regular occupation for pay or profit for which the Covered Person is entitled to benefits under any Workers’ Compensation Law, Employer’s Liability Law or similar law. You must promptly claim and notify the Company of all such benefits.

16. Local, state and/or federal taxes, except where MetLife is required by law to pay.

17. Services: · for which the employer of the person receiving such services is required to pay; or · received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

18. Services or materials received as a result of disease, defect, or injury due to war or an act of war (declared or undeclared), taking part in a riot or insurrection, or committing or attempting to commit a felony.

19. Services and materials obtained while outside the United States, except for emergency vision care.

20. Services, procedures, or materials for which a charge would not have been made in the absence of insurance.

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VISION INSURANCE: COORDINATION OF BENEFITS When You or a Dependent incur charges for Covered Services and Materials, there may be other Plans, as defined below, that also provide benefits for those same charges. In that case, We may reduce what We pay based on what the other Plans pay. This Coordination of Benefits section explains how and when We do this.

DEFINITIONS In this section, the terms set forth below have the following meanings: Allowable Expense means a necessary vision expense for which both of the following are true: ·

a Covered Person must pay it, and

·

it is at least partly covered by one or more of the Plans that provide benefits to the Covered Person.

If a Plan provides fixed benefits for specified events or conditions (instead of benefits based on expenses incurred) such benefits are Allowable Expenses.

If a Plan provides benefits in the form of services, We treat the reasonable cash value of each service performed as both an Allowable Expense and a benefit paid by that Plan.

The term does not include: ·

expenses for services performed because of a Job-Related Injury or Sickness;

·

any amount of expenses in excess of the higher reasonable and customary fee for a service, if two or more Plans compute their benefit payments on the basis of reasonable and customary fees;

·

any amount of expenses in excess of the higher negotiated fee for a service, if two or more Plans compute their benefit payments on the basis of negotiated fees; and

·

any amount of benefits that a Primary Plan does not pay because the covered person fails to comply with the Primary Plan’s managed care or utilization review provisions, these include provisions requiring: · · · ·

second surgical opinions; pre-certification of services; use of providers in a Plan’s network of providers; or any other similar provisions.

If You or a Dependent are also covered under an HMO plan, We will not use this provision to refuse to pay benefits because an HMO member has elected to have vision services provided by a non-HMO provider and the HMO's contract does not require the HMO to pay for providing those services.

Claim Determination Period means a calendar year or plan year. A Claim Determination Period for any Covered Person will not include periods of time during which that person is not covered under This Plan.

Custodial Parent means a Parent awarded custody, other than joint custody, by a court decree. In the absence of a court decree, it means the Parent with whom the child resides more than half of the Year without regard to any temporary visitation.

HMO means a Health Maintenance Organization or Vision Health Maintenance Organization.

Job-Related Injury or Sickness means any injury or sickness: ·

for which You are entitled to benefits under a workers’ compensation or similar law, or any arrangement that provides for similar compensation; or

·

arising out of employment for wage or profit.

Parent means a person who covers a child as a dependent under a Plan.

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VISION INSURANCE: COORDINATION OF BENEFITS (continued) Plan means any of the following if it provides benefits or services for an Allowable Expense: ·

a group insurance plan;

·

an HMO;

·

a blanket plan;

·

uninsured arrangements of group or group type coverage;

·

a group practice plan;

·

a group service plan;

·

a group prepayment plan;

·

any other plan that covers people as a group;

·

any other coverage required or provided by any law or any governmental program, except Medicaid.

The term does not include any of the following: ·

individual or family insurance or subscriber contracts;

·

individual or family coverage through closed panel Plans or other prepayment, group practice or individual practice Plans;

·

hospital indemnity coverage;

·

a school blanket plan that only provides accident-type coverage on a 24 hour basis, or a "to and from school basis," to students in a grammar school, high school or college;

·

disability income protection coverage;

·

accident only coverage;

·

specified disease or specified accident coverage;

·

nursing home or long term care coverage; or

·

any government program or coverage if, by state or Federal law, its benefits are excess to those of any private insurance plan or other non-government plan.

The provisions of This Plan which limit benefits based on benefits or services provided under Plans which the employer, Policyholder (or an affiliate) contributes to or sponsors will not be affected by these Coordination of Benefits provisions.

Each policy, contract or other arrangement for benefits is a separate Plan. If part of a Plan reserves the right to reduce what it pays based on benefits or services provided by other Plans, that part will be treated separately from any parts which do not.

This Plan means the vision benefits described in this certificate, except for any provisions in this certificate that limit insurance based on benefits for services provided under plans which the Policyholder (or an affiliate) contributes to or sponsors.

Primary Plan means a Plan that pays its benefits first under the “Rules to Decide Which Plan Is Primary” section. A Primary Plan pays benefits as if the Secondary Plans do not exist.

Secondary Plan means a Plan that is not a Primary Plan. A Secondary Plan may reduce its benefits by amounts payable by the Primary Plan. If there are more than two Plans that provide coverage, a Plan may be Primary to some plans, and Secondary to others.

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VISION INSURANCE: COORDINATION OF BENEFITS (continued) RULES TO DECIDE WHICH PLAN IS PRIMARY When more than one Plan covers the person for whom Allowable Expenses were incurred, We determine which plan is primary by applying the rules in this section.

When there is a basis for claim under This Plan and another Plan, This Plan is Secondary unless: ·

the other Plan has rules coordinating its benefits with those of This Plan; and

·

this Plan is primary under This Plan’s rules.

The first rule below which will allow Us to determine which Plan is Primary is the rule that We will use.

Dependent or Non-Dependent: A Plan that covers a person other than as a dependent (for example, as an employee, member, subscriber, or retiree) is Primary and shall pay its benefits before a Plan that covers the person as a dependent; except that if the person is a Medicare beneficiary and, as a result of federal law or regulations, Medicare is: ·

Secondary to the Plan covering the person as a dependent; and

·

Primary to the Plan covering the person as other than a dependent (e.g., a retired employee),

then the order of benefits between the two Plans is reversed and the Plan that covers the person as a dependent is Primary.

Child Covered Under More Than One Plan – Court Decree: When This Plan and another Plan cover the same Child as the Dependent of two or more Parents, and the specific terms of a court decree state that one of the Parents must provide health coverage or pay for the Child’s health care expenses, that Parent’s Plan is Primary if the Plan has actual knowledge of those terms. This rule applies to Claim Determination Periods that start after the Plan is given notice of the court decree.

Child Covered Under More Than One Plan – The Birthday Rule: When This Plan and another Plan cover the same Child as the Dependent of two or more Parents, the Primary Plan is the Plan of the Parent whose birthday falls earlier in the Year if: ·

the Parents are married; or

·

the Parents are not separated (whether or not they have ever married); or

·

a court decree awards joint custody without specifying which Parent must provide health coverage.

If both Parents have the same birthday, the Plan that covered either of the Parents longer is the Primary Plan.

However, if the other Plan does not have this rule, but instead has a rule based on the gender of the parent, and if as a result the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of benefits.

Child Covered Under More than One Plan – Custodial Parent: When This Plan and another Plan cover the same Child as the Dependent of two or more Parents, if the Parents are not married, or are separated (whether or not they ever married), or are divorced, the Primary Plan is: ·

the Plan of the Custodial Parent; then

·

the Plan of the spouse of the Custodial Parent; then

·

the Plan of the non-custodial Parent; and then

·

the Plan of the spouse of the non-custodial Parent.

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VISION INSURANCE: COORDINATION OF BENEFITS (continued) Active or Inactive Employee: A Plan that covers a person as an employee who is neither laid off nor retired is Primary to a Plan that covers the person as a laid-off or retired employee (or as that person’s Dependent).

If the other Plan does not have this rule and, if as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Continuation Coverage: The Plan that covers a person as an active employee, member or subscriber (or as that employee’s Dependent) is Primary to a Plan that covers that person under a right of continuation pursuant to federal law (e.g., COBRA) or state law. If the Plan that covers the person has not adopted this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule shall not apply.

Longer/Shorter Time Covered: If none of the above rules determine which Plan is Primary, the Plan that has covered the person for the longer time shall be Primary to a Plan that has covered the person for a shorter time.

No Rules Apply: If none of the above rules determine which Plan is Primary, the Allowable Expenses shall be shared equally between all the Plans. In no event will This Plan pay more than it would if it were Primary.

EFFECT ON BENEFITS OF THIS PLAN If This Plan is Secondary, when the total Allowable Expenses incurred by a covered person in any Claim Determination Period are less than the sum of: ·

the benefits that would be payable under This Plan without applying this Coordination of Benefits provision; and

·

the benefits that would be payable under all other Plans without applying Coordination of Benefits or similar provisions;

then We will reduce the benefits that would otherwise be payable under This Plan. The sum of these reduced benefits plus all benefits payable for such Allowable Expenses under all other Plans will not exceed the total of the Allowable Expenses. Benefits payable under all other Plans include all benefits that would be payable if the proper claims had been made on time.

FACILITY OF PAYMENT A payment made under another Plan may include an amount which should have been paid under This Plan.

If it does, We may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The term “payment made” includes benefits provided in the form of services, in which case We may pay the reasonable cash value of the benefits provided in the form of services.

RIGHT OF RECOVERY If the amount We pay is more than We should have paid under this Coordination of Benefits provision, We may recover the excess from one or more of: ·

the person We have paid or for whom We have paid;

·

insurance companies; or

·

other organizations.

The amount of the payment includes the reasonable cash value of any benefits provided in the form of services.

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VISION INSURANCE: FILING A CLAIM CLAIMS FOR VISION INSURANCE If you select an In Network Vision Provider, You do not need to file a claim.

If you select an Out-of-Network Vision Provider, You may provide full payment to the Out-of-Network Vision Provider at the time of service and submit the invoice including an itemized statement of charges with Your claim form, or You may be able to assign the claim to the Out-of-Network Vision Provider. If the Out-ofNetwork Vision Provider accepts the assignment, the provider will submit the claim on your behalf. You will be responsible for any charges not covered by the Plan.

Out of network claim forms needed to file for benefits under the group insurance program can be obtained by calling MetLife at 1-855-METEYE1. Vision claim forms can also be downloaded from www.metlife.com/mybenefits. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim.

When We receive the claim form and Proof, Your claim will be paid subject to the terms and provisions of this certificate and the Group Policy.

CLAIMS FOR VISION INSURANCE BENEFITS When a claimant files a claim for Vision Insurance benefits described in this certificate, both the notice of claim and the required Proof should be sent to Us within 180 days from the date of service.

Claim and Proof may be given to Us by following the steps set forth below: Step 1 A claimant can request a claim form by downloading it from www.metlife.com/mybenefits.

Step 2 Complete the claim form as instructed and return it with the invoice.

Step 3 The claimant must give Us Proof not later than 180 days from the date of service.

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VISION INSURANCE: PROCEDURES FOR VISION CLAIMS Routine Questions on Vision Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1855-METEYE1.

Claim Denial Appeals If a claim is denied in whole or in part, under the terms of this certificate, a request may be submitted to Us by a Covered Person or a Covered Person’s authorized representative for a full review of the denial. A Covered Person may designate any person, including their provider, as their authorized representative. References in this section to “Covered Person” include the Covered Person’s authorized representative, where applicable.

Initial Appeal. All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. A Covered Person may review, during normal business hours, any documents used by Us pertinent to the denial. A Covered Person may also submit Written comments or supporting documentation concerning the claim to assist in Our review. Our response to the initial appeal, including specific reasons for the decision, shall be communicated to the Covered Person within thirty (30) calendar days after receipt of the request for the appeal.

Second Level Appeal. If a Covered Person disagrees with the response to the initial appeal of the denied claim, the Covered Person has the right to a second level appeal. A request for a second level appeal must be submitted to Us within sixty (60) calendar days after receipt of Our response to the initial appeal. We shall communicate Our final determination to the Covered Person within thirty (30) calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations. Our communication to the Covered Person shall include the specific reasons for the determination.

Other Remedies. When a Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation or arbitration. Additional information is available from the U.S. Department of Labor or the insurance regulatory agency for the Covered Persons’ state of residency. Additionally, under the provisions of ERISA (Section 502(a)(1)(B) 29 U.S.C. 1132(a)(1)(B)), the Covered Person has the right to bring a civil action when all available levels of reviews, including the appeal process, have been completed. ERISA remedies may apply in those instances where the claims were not approved in whole or in part as the result of appeals under this Policy and the Covered Person disagrees with the outcome of such appeals.

Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the Covered Person exhausting his/her rights under this Policy and/or prior to the expiration of sixty (60) calendar days after the claim and any applicable documentation has been filed with Us. No such action shall be brought after the expiration of any applicable statute of limitations, in accordance with the terms of this Policy. No such action shall be brought after the expiration of three (3) years from the last date that the claim and any applicable invoices were submitted to Us, and no such action shall be brought at all unless brought within three (3) years from the expiration of the time within which such materials are required to be submitted in accordance with the terms of this Policy.

Insurance Fraud: Any Covered Person who intends to defraud, knowingly facilitates a fraud, submits a claim containing false or deceptive information, or who commits any other similar act as defined by applicable state or federal law, may be guilty of insurance fraud. Such an act is grounds for immediate termination of the coverage under this Policy of the Covered Person committing such fraud.

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GENERAL PROVISIONS Assignment The rights and benefits under the Group Policy are not assignable prior to a claim for benefits, except as required by law.

Upon receipt of a Covered Service, You may assign Vision Insurance benefits to the Vision Provider providing such service.

Vision Insurance: Who We Will Pay If You assign payment of Vision Insurance benefits to Your or Your Dependentâ&#x20AC;&#x2122;s Vision Provider, We will pay benefits directly to the Vision Provider. Otherwise, We will pay Vision Insurance benefits to You. Entire Contract Your insurance is provided under a contract of group insurance with the Employer. The entire contract with the Employer is made up of the following: 1. the Group Policy and its Exhibits, which include the certificate(s); 2. the Employer's application; and 3. any amendments and/or endorsements to the Group Policy.

Incontestability: Statements Made by You Any statement made by You will be considered a representation and not a warranty.

Evidence of insurability will not be required nor will any statement made by You, which relates to insurability, be used: 1. to contest the validity of the insurance benefits; or 2. to reduce the insurance benefits.

Conformity with Law If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be interpreted to so conform.

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THE PRECEDING PAGE IS THE END OF THE CERTIFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION.

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ERISA INFORMATION THIS SUMMARY PLAN DESCRIPTION IS EXPRESSLY MADE PART OF THE PLAN AND IS LEGALLY ENFORCEABLE AS PART OF THE PLAN WITH RESPECT TO ITS TERMS AND CONDITIONS. IN THE EVENT THERE IS NO OTHER PLAN DOCUMENT, THIS DOCUMENT SHALL SERVE AS A SUMMARY PLAN DESCRIPTION AND SHALL ALSO CONSTITUTE THE PLAN. NAME OF THE PLAN BRG Management Inc dba Aspen Heights Welfare Benefit Plan ("Plan") NAME AND ADDRESS OF EMPLOYER BRG Management Inc dba Aspen Heights 1301 S Capital of Texas Hwy Austin, TX 787460 (512) 369-3030 EMPLOYER IDENTIFICATION NUMBER: 262458511 COVERAGE

PLAN NAME

Vision

BRG Management Inc dba Aspen Heights Welfare Benefit Plan

TYPE OF ADMINISTRATION The above listed benefits are insured by Metropolitan Life Insurance Company ("MetLife").

PLAN ADMINISTRATOR NAME, BUSINESS ADDRESS AND PHONE NUMBER BRG Management Inc dba Aspen Heights 1301 S Capital of Texas Hwy Austin, TX 787460 (512) 369-3030 AGENT FOR SERVICE OF LEGAL PROCESS For disputes arising under the Plan, service of legal process may be made upon the Plan Administrator at the above address. For disputes arising under those portions of the Plan insured by MetLife, service of legal process may be made upon MetLife at one of its local offices, or upon the supervisory official of the Insurance Department in the state in which you reside.

ELIGIBILITY FOR PARTICIPATION; DESCRIPTION OR SUMMARY OF BENEFITS Your MetLife certificate describes the eligibility requirements for insurance provided by MetLife under the Plan. It also includes a detailed description of the insurance provided by MetLife under the Plan.

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The following applies to employers with 20 or more employees that are not church or government plans: NOTICE OF YOUR RIGHT AND YOUR DEPENDENTS' RIGHT TO COBRA CONTINUATION COVERAGE COBRA is a federal law that requires most group health plans to give their employees and their dependents the opportunity to continue coverage when coverage is terminated due to certain specific events. If your employment terminates for any reason other than your gross misconduct, or if your hours worked are reduced so that your coverage terminates, you and your covered dependents may be able to continue coverage under This Plan for a period of up to 18 months. If it is determined under the terms of the Social Security Act that You or your covered dependent is disabled within the first 60 days of COBRA coverage, you and your covered dependents may be able to continue your vision coverage under This Plan for an additional 11 months after the expiration of the 18 month period. In addition, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents may be able to continue coverage under This Plan for up to 36 months. Also, your covered children may be able to continue coverage under This Plan for up to 36 months after they no longer qualify as covered dependents under the terms of This Plan. Group health plans for employers with fewer than 20 employees, church plans, and plans established and maintained by the federal government are not subject to COBRA continuation requirements.

During the continuation period, a child of yours that is (1) born; (2) adopted by you; or (3) placed with you for adoption, will be treated as if the child were a covered dependent at the time coverage was lost due to an event described above.

This continuation will terminate on the earliest of: a. the end of the 18, 29 or 36 month continuation period, as the case may be; b. the date of expiration of the last period for which the required payment was made; c.

the date, after you or your covered dependent elects to continue coverage, that you or your covered dependent first becomes covered under another group health plan as long as the new plan does not contain any exclusion or limitation with respect to your or your covered dependentâ&#x20AC;&#x2122;s preexisting condition;

d. the date your employer ceases to provide any group health plan for its employees.

Notice will be given when you or your covered dependent becomes entitled to continue coverage under This Plan. You or your covered dependent will then have 60 days to elect to continue coverage. If you or your covered dependent do not notify your Employer within the 60-day election period, you will lose the option to elect continuation coverage.

Each person who is eligible for COBRA coverage is entitled to make a separate election of COBRA coverage. Thus, a covered spouse (as defined by federal law) or dependent child (or parent on their behalf) is entitled to elect COBRA coverage even if the covered Employee does not make that election.

However, covered Employees may elect COBRA coverage on behalf of their covered dependents. Any person who elects to continue coverage under This Plan must pay the full cost of that coverage (including both the share you now pay and the share your Employer now pays), plus any additional amounts permitted by law. Your payments for continued coverage must be made on the first day of each month in advance.

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If you do not elect COBRA coverage, your vision coverage will end. However, if you initially waive COBRA continuation coverage before the end of the 60-day election period, you may change your election by sending the completed election form to the Plan Administrator and postmarking it no later than the last day of the 60-day election period.

If You Elect Cobra If you choose COBRA coverage and pay the required premiums, you are entitled to coverage which, as of the time coverage is being provided, is identical to the coverage provided by the Employer to similarly situated active Employees, spouses or dependent children. This means that if the coverage for similarly situated Employees spouses or dependent children changes, coverage will change for those who elected COBRA coverage.

Duration Of Cobra Coverage The law requires that you be given the opportunity to maintain COBRA coverage for 36 months from the date coverage ends as a result of the qualifying event unless you lost coverage because of the covered Employee's termination of employment or reduction in hours. In that case, the required COBRA coverage period is 18 months from the date you lose coverage as a result of the termination of employment or reduction in hours. However, the 18-month coverage period may be extended under the following circumstances: Disability. If any person entitled to COBRA coverage (the covered Employee, covered spouse or covered dependent child) is determined by the Social Security Administration to have been disabled at any time during the first 60 days of COBRA coverage period and the disability lasts at least until the end of the 18 month period of continuation coverage, then all such persons entitled to elect COBRA coverage may be able to continue coverage for up to 29 months, rather than 18 months.

In order to be eligible for the additional 11 months of COBRA coverage, the covered Employee, covered spouse or covered dependent child must notify the Employer's COBRA Administrator within 60 days of the latest of: (1) the Social Security Administration’s determination of disability; (2) the date of the qualifying event; (3) the date on which the covered Employee’s coverage initially was or will be lost; or (4) the date a person entitled to COBRA coverage is informed of this obligation by being provided the initial COBRA notice for the applicable group health plan. Written notice to the COBRA Administrator must be received before the end of the initial 18-month coverage period. A copy of the Social Security Administration’s determination must be provided to the COBRA Administrator. If these procedures are not followed, there will be no disability extension of COBRA. During the additional 11 months of coverage, your cost for that coverage will be approximately 50% higher than it was during the preceding 18 months.

The additional 11 months of coverage provided on account of a disability will end as of the earlier of: ·

The first day of the month beginning more than 30 days after a final determination by the Social Security Administration that the disability no longer exists; or

·

The last day of the 29th month of total coverage.

A person entitled to COBRA coverage must notify the COBRA Administrator within 30 days if the Social Security Administration determines that the disabled person is no longer disabled. This Plan reserves the right to retroactively cancel COBRA coverage, and will require reimbursement of all benefits paid for claims incurred after coverage terminates.

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Subsequent Qualifying Events. If, during the 18-month period of COBRA coverage (or within the 29month maximum coverage period in the case of a disability extension), the covered Employee and the spouse divorce, the covered Employee dies, the covered Employee becomes entitled to Medicare, or a dependent ceases to be an eligible dependent under the terms of This Plan, then the covered spouse and/or covered dependent child(ren) (as applicable) may be able to extend COBRA coverage for up to 36 months from the date of the termination of employment or reduction in hours.

A person entitled to COBRA coverage must notify the Employerâ&#x20AC;&#x2122;s COBRA Administrator of the subsequent event no later than 60 days after its occurrence. If such notification is not given, the covered spouse and/or covered dependent child will not be entitled to the additional COBRA coverage.

Premiums For Cobra Coverage A person entitled to COBRA coverage is entirely responsible for paying the premiums for COBRA coverage. The required payment for each continuation coverage period for each option will be described in the notice that is sent when an individual experiences a qualifying event.

Initial Premium Payment If continuation of coverage is elected, payment for continuation coverage must be made no later than 45 days after the date of such election. (This is the date the election notice is post-marked, if mailed.) If the first payment for continuation coverage is not made in full by the 45th day after the date of election, continuation coverage under This Plan will end. A person entitled to COBRA coverage is responsible for making sure that the amount of the first payment is correct.

After the first payment for continuation coverage, the amount due for each coverage period for each qualified beneficiary will be provided when coverage is elected.

PLAN TERMINATION OR CHANGES Written notice of termination must be given to the Employer at least 31 days prior to the date such insurance will be terminated.

Premiums are due and payable on the first day of each month for which insurance coverage is to be provided. If a payment is not received within 31 days after the due date, coverage will terminate as follows: a. with respect to coverages other than Life Insurance and Accidental Death or Dismemberment Insurance - on the earlier of the 31st day following the due date and the date requested in writing by the Employer, provided such request is made before such 31st day; and b. with respect to Life Insurance and Accidental Death or Dismemberment Insurance -- on the later of the 31st day following the due date and the date MetLife's written notice of termination is received by the Employer.

The Employer is liable to MetLife for payment of the pro-rata premium which accrues while any coverage remains in force.

The group policy sets forth those situations in which the Employer and/or MetLife have the right to end the policy.

The Employer reserves the right to change or terminate the Plan at any time. Therefore, there is no guarantee that you will be eligible for the benefits described herein for the duration of your employment.

Any such action will be taken only after careful consideration.

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Your consent or the consent of your beneficiary is not required to terminate, modify, amend, or change the Plan.

In the event Your coverage ends in accord with the Date Your Insurance Ends provision of Your certificate, you may still be eligible to receive benefits. The circumstances under which benefits are available are described in Your MetLife certificate.

CONTRIBUTIONS You must make a contribution to the cost of Personal and Dependent Vision Insurance.

The total premium rate for insurance provided under the Plan by MetLife is set by MetLife.

PLAN YEAR The Plan's fiscal records are kept on a Plan year basis beginning each January 1 and ending on the following December 31.

Qualified Domestic Relations Orders/Qualified Medical Child Support Orders You and your beneficiaries can obtain, without charge, from the Plan Administrator a copy of any procedures governing Qualified Domestic Relations Orders (QDRO) and Qualified Medical Child Support Orders (QMCSO).

Routine Questions on Vision Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-855-METEYE1.

Claim Denial Appeals If a claim is denied in whole or in part, under the terms of this certificate, a request may be submitted to Us by a Covered Person or a Covered Person’s authorized representative for a full review of the denial.

A Covered Person may designate any person, including their provider, as their authorized representative.

References in this section to “Covered Person” include the Covered Person’s authorized representative, where applicable.

Initial Appeal. All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. A Covered Person may review, during normal business hours, any documents used by Us pertinent to the denial. A Covered Person may also submit Written comments or supporting documentation concerning the claim to assist in Our review. Our response to the initial appeal, including specific reasons for the decision, shall be communicated to the Covered Person within thirty (30) calendar days after receipt of the request for the appeal.

Second Level Appeal. If a Covered Person disagrees with the response to the initial appeal of the denied claim, the Covered Person has the right to a second level appeal. A request for a second level appeal must be submitted to Us within sixty (60) calendar days after receipt of Our response to the initial appeal. We shall communicate Our final determination to the Covered Person within thirty (30) calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations.

Our communication to the Covered Person shall include the specific reasons for the determination.

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Other Remedies. When a Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation or arbitration.

Additional information is available from the U.S. Department of Labor or the insurance regulatory agency for the Covered Personsâ&#x20AC;&#x2122; state of residency. Additionally, under the provisions of ERISA (Section 502(a)(1)(B) 29 U.S.C. 1132(a)(1)(B)), the Covered Person has the right to bring a civil action when all available levels of reviews, including the appeal process, have been completed. ERISA remedies may apply in those instances where the claims were not approved in whole or in part as the result of appeals under this Policy and the Covered Person disagrees with the outcome of such appeals.

Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the expiration of sixty (60) calendar days after the claim and any applicable documentation has been filed with Us. No such action shall be brought after the expiration of any applicable statute of limitations from the time Written Proof of loss is required to be given.

Insurance Fraud: Any Covered Person who intends to defraud, knowingly facilitates a fraud, submits a claim containing false or deceptive information, or who commits any other similar act as defined by applicable state or federal law, may be guilty of insurance fraud. Such an act is grounds for immediate termination of the coverage under this Policy of the Covered Person committing such fraud.

Discretionary Authority of Plan Administrator and Other Plan Fiduciaries In carrying out their respective responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

STATEMENT OF ERISA RIGHTS The following statement is required by federal law and regulation.

As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan administrator's office and at other specified locations, all Plan documents governing the Plan, including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefit Security Administration.

Obtain, upon written request to the Plan administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the Plan's annual financial report. The Plan administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue Group Vision Plan Insurance Continue vision insurance for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.

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Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.

No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan administrator to provide the materials and pay you up to $110.00 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court.

In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court.

If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court.

The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees.

If you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is frivolous.

Assistance with Your Questions If you have any questions about your Plan, you should contact the Plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

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PLAN PRIVACY INFORMATION Notwithstanding any other Plan provision in this or other sections of the Plan, the Plan will operate in accordance with the HIPAA privacy laws and regulations as set forth in 45 CFR Parts 160 and 164, and as they may be amended ("HIPAA"), with respect to protected health information ("PHI") as that term is defined therein. The Plan Administrator and/or his or her designee retains full discretion in interpreting these rules and applying them to specific situations. All such decisions shall be given full deference unless the decision is determined to be arbitrary and capricious.

The term “Plan Sponsor” means BRG Management Inc. The term “Plan Administrator” means the entity designated as Plan Administrator by the Plan documents pursuant to which the plan is operated. If a Plan Administrator is not designated by the plan documents, the Plan Sponsor shall be deemed to be the Plan Administrator.

I. Permitted Uses and Disclosures of PHI by the Plan and the Plan Sponsor The Plan and the Plan Sponsor are permitted to use and disclose PHI for the following purposes, to the extent they are not inconsistent with HIPAA: ·

For general plan administration, including policyholder service functions, enrollment and eligibility functions, reporting functions, auditing functions, financial and billing functions, to assist in the administration of a consumer dispute or inquiry, and any other authorized insurance or benefit function.

·

As required for computer programming, consulting or other work done in respect to the computer programs or systems utilized by the Plan.

·

Other uses relating to plan administration, which are approved in writing by the Plan Administrator.

·

At the request of an individual, to assist in resolving claims the individual may have with respect to benefits under the Plan.

II. Uses and Disclosures of PHI by the Plan and the Plan Sponsor for Required Purposes The Plan and Plan Sponsor may use or disclose PHI for the following required purposes: ·

Judicial and administrative proceedings, in response to lawfully executed process, such as a court order or subpoena.

·

For public health and health oversight activities, and other governmental activities accompanied by lawfully executed process.

·

As otherwise may be required by law.

ASPEN 2018 BENEFITS :: 352

III. Sharing of PHI With the Plan Sponsor As a condition of the Plan Sponsor receiving PHI from the Plan, the Plan Documents have been amended to incorporate the following provisions, under which the Plan Sponsor agrees to: ·

Not use or further disclose PHI other than as permitted or required by the plan documents in Sections I and II above;

·

Ensure that any agents to whom it provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor;

·

Not use or disclose PHI for employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor;

·

Report to the Plan any use or disclosure of the information that is inconsistent with the permitted uses or disclosures of which it becomes aware;

·

Make PHI available to Plan participants for the purposes of the rights of access and inspection, amendment, and accounting of disclosures as required by HIPAA;

·

Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the Plan with HIPAA;

·

If feasible, return or destroy all PHI received from the Plan that the sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible;

·

Ensure that adequate separation between the Plan and Plan Sponsor is established in accordance with the following requirements: (A) Employees to be Given Access to PHI: The following employees (or class of employees) of the Plan Sponsor are the only individuals that may access PHI provided by the Plan: Human Resource Director (B) Restriction to Plan Administration Functions: The access to and use of PHI by the employees of the Plan Sponsor designated above will be limited to plan administration functions that the Plan Sponsor performs for the Plan.

(C) Mechanism for Resolving issues of Noncompliance: If the Plan Administrator determines that an employee of the Plan Sponsor designated above has acted in noncompliance with the plan document provisions outlined above, then the Plan Administrator shall take or seek to have taken appropriate disciplinary action with respect to that employee, up to and including termination of employment as appropriate. The Plan Administrator shall also document the facts of the violation, actions that have been taken to discipline the offending party and the steps taken to prevent future violations.

Certify to the Plan, prior to the Plan permitting disclosure of PHI to the Plan Sponsor, that the Plan Documents have been amended to incorporate the provisions in this Section.

ASPEN 2018 BENEFITS :: 353

IV. Security As a condition of the Plan Sponsor receiving electronic PHI (“ePHI”) from the Plan, the Plan Documents have been amended to incorporate the following provisions, under which the Plan Sponsor agrees to: ·

Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the ePHI that it creates, receives, maintains, or transmits on behalf of the Plan;

·

Ensure that the adequate separation between the Plan and the Plan Sponsor, which is required by the applicable section(s) of the Plan relating to the sharing of PHI with the Plan Sponsor, is supported by reasonable and appropriate security measures;

·

Ensure that any agent to whom it provides ePHI agrees to implement reasonable and appropriate security measures to protect the information; and

·

Report to the Plan any security incident of which it becomes aware. In this context, the term “security incident” means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in information systems such as hardware, software, information, data, applications, communications, and people.

FUTURE OF THE PLAN

It is hoped that This Plan will be continued indefinitely, but BRG Management Inc dba Aspen Heights reserves the right to change or terminate the Plan in the future. Any such action would be taken only after careful consideration.

ASPEN 2018 BENEFITS :: 354

Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally.

Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals.

Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us.

Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses.

How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.

Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to: · · · · · · ·

administer your products and services process claims and other transactions perform business research confirm or correct your information market new products to you help us run our business comply with applicable laws

Sharing Your Information With Others We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.

Other reasons we may share your information include: doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) · telling another company what we know about you if we are selling or merging any part of our business · giving information to a governmental agency so it can decide if you are eligible for public benefits CPN-Group-Ann-2015 ·

ASPEN 2018 BENEFITS :: 355

· · · ·

giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account) giving your information to your health care provider having a peer review organization evaluate your information, if you have health coverage with us those listed in our “Using Your Information” section above HIPAA

We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance.

Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you.

You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. Select “Privacy Policy” at the bottom of the home page. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAprivacyAmericasUS@metlife.com, or call us at telephone number (212) 578-0299.

Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you anything we learned as part of a claim or lawsuit, unless required by law.

If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records.

Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife.

Questions We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us.

When you write, include your name, address, and policy or account number.

Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI 02887-9954 privacy@metlife.com We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies: Metropolitan Life Insurance Company MetLife Insurance Company USA SafeGuard Health Plans, Inc.

MetLife Health Plans, Inc. General American Life Insurance Company SafeHealth Life Insurance Company

CPN-Group-Ann-2015

ASPEN 2018 BENEFITS :: 356

Uniformed Services Employment And Reemployment Rights Act This section describes the right that you may have to continue coverage for yourself and your covered dependents under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).

Continuation of Group Vision Insurance: If you take a leave from employment for “service in the uniformed services,” as that term is defined in USERRA, and as a consequence your vision insurance coverage under your employer’s group vision insurance policy ends, you may elect to continue vision insurance for yourself and your covered dependents, for a limited period of time, as described below.

The law requires that your employer notify you of your rights, benefits and obligations under USERAA including instructions on how to elect to continue insurance, the amount and procedure for payment of premium. If permitted by USERRA, your employer may require that you elect to continue coverage within a period of time specified by your employer.

You may be responsible for payment of the required premium to continue insurance. If your leave from employment for service in the uniformed services lasts less than 31 days, your required premium will be no more than the amount you were required to pay for vision insurance before the leave began; for a leave lasting 31 or more days, you may be required to pay up to 102% of the total Vision insurance premium, including any amount that your employer was paying before the leave began.

You and your covered dependents insurance that is continued pursuant to USERRA will end on the earliest of the following: · ·

the end of 24 consecutive months from the date your leave from employment for service in the uniformed services begins; or the day after the date on which you fail to apply for, or return to employment, in accordance with USERRA.

You and your covered dependent may become entitled to continuation of coverage under the Consolidated Omnibus Budget Reconciliation Act (“COBRA”) while you have Vision insurance coverage under your employer’s group vision insurance policy pursuant to USERRA. Contact your employer for more information.

ASPEN 2018 BENEFITS :: 357

2018 Aspen Heights Open Enrollment

ASPEN 2018 BENEFITS :: 358

DISCLAIMER This disclaimer applies to all information contained in this presentation.

This presentation provides general information only and is not intended as legal advice.

In the case of any inconsistencies between the information presented here and the plan document, the plan document prevails.

For complete information, please see your plan document.

2 ASPEN 2018 BENEFITS :: 359

Trend Analysis

You are Here

3 ASPEN 2018 BENEFITS :: 360

Medical Pricing Changes Per Pay Period 2017 Employee Rates

2018 Employee Rates

$100.00

$110.00

$234.84

$258.33

$184.36

$202.80

EE + Family

$324.68

$357.15

Employee

$15.00

$20.00

EE + SP

$30.00

$37.50

EE + Ch(ren)

$20.00

$27.50

EE + Family

$40.00

$50.00

Employee Traditional EE + SP Copay Plan EE + Ch(ren)

HDHP (H.S.A.)

4 ASPEN 2018 BENEFITS :: 361

Dental & Vision Pricing Changes Per Pay Period

Dental

Vision

2017 Employee Rates

2018 Employee Rates

Employee

$5.00

$5.45

EE + SP

$14.50

$15.81

EE + Ch(ren)

$15.00

$16.35

EE + Family

$25.00

$27.25

Employee

$1.00

$1.00

EE + SP

$3.00

$3.00

EE + Ch(ren)

$3.00

$3.00

EE + Family

$5.50

$5.50

5 ASPEN 2018 BENEFITS :: 362

Action Items!

• No plan design changes for medical, dental or vision. Elections will

roll over at the new 2018 rates if no changes are made during Open Enrollment.

• If you want Voluntary Life or Voluntary LTD coverage,

EMPLOYEES MUST ACTIVELY ENROLL IN: • Voluntary Life and AD&D • Voluntary Long Term Disability

• Please also remember to update your H.S.A. elections for 2018

through Tango.

6 ASPEN 2018 BENEFITS :: 363

Open Enrollment Overview Nov. 1 – Nov. 15

Benefit Medical – 2 Options Health Savings Account (HSA) Flexible Spending Accounts Dental Telemedicine Vision

Changes Effective: January 1, 2018

Qualifying Events

Provider BCBSTX Tango/Optum Bank ADP/WageWorks MetLife First Stop Health NEW! MetLife

Life AD&D & Voluntary Life AD&D

Liberty Mutual NEW! MUST ENROLL

Short-Term Disability

Liberty Mutual NEW!

Voluntary Long-Term Disability

Liberty Mutual NEW! MUST ENROLL

Parental Leave

Aspen Heights NEW!

Employee Assistance Program (EAP)

LifeCare/ADP Liberty Mutual NEW!

401(k)

ADP

7 ASPEN 2018 BENEFITS :: 364

BCBSTX â&#x20AC;&#x201C; Traditional Copay Health Plan Services

Blue Choice Network In-Network

Primary Care / Specialist Office Visit Preventive Visit Individual / Family Deductible Coinsurance Out-of-Pocket Maximum Emergency Room Urgent Care Prescription Drugs Mail Order 3x Prescription Drugs Out-of-Pocket Maximum

$25 (no deductible) 100% (no deductible) $1,000 / $3,000 Insurance pays 80% after your deductible $4,000 / $10,200 80% after deductible after $100 Copay $50 (no deductible) $20 / $35 / $50 (no deductible) $1,000 / $3,000

8 ASPEN 2018 BENEFITS :: 365

BCBSTX – High Deductible Health Plan (“HDHP”) Services

Blue Choice Network In-Network

Primary Care / Specialists Office Visit Preventive Visit Individual / Family Deductible Coinsurance Out-of-Pocket Maximum

Deductible 100% (no deductible) $5,000 / $10,000 100% $5,000 / $10,000

Emergency Room

Deductible

Urgent Care

Deductible

Prescription Drugs

Deductible

9 ASPEN 2018 BENEFITS :: 366

GOOD NEWS!

â&#x20AC;¢ CVS Caremark is BACK IN-NETWORK with Blue Cross Blue

Shield of Texas effective 1/1/18

10 ASPEN 2018 BENEFITS :: 367

Health Savings Account (HSA)

• Employee Owned bank account • No “use it or lose it” provision

hsa.tangohealth.com

• AH deposits money each pay period • May only enroll in HSA if enrolled in the HDHP • Save your itemized receipts from providers

11 ASPEN 2018 BENEFITS :: 368

HSA Eligibility Must be enrolled in HDHP Not covered by another plan that is NOT a HDHP Are not covered by a healthcare FSA

Are not enrolled in Medicare, Medicaid or TriCare

12 ASPEN 2018 BENEFITS :: 369

HSA Tax Advantaged Savings Funds can be used for current health care (medical, dental, vision, chiropractic, etc) expenses, or saved for future health care expenses, COBRA or Long-Term Care premiums, Medicare Supplement premiums or other eligible expenses you incur later.

Use this account like a healthcare 401(k) account to build your nest egg.

HSA

HSA

HSA

• Contribute Pre-Tax • Invest Tax-Free

• Accumulate Tax-Free

• Spend Tax-Free on Qualified Expenses HSA

HSA

• IRS Publication 502

13 ASPEN 2018 BENEFITS :: 370

Annual HSA Funding IRS HSA Contribution Maximums*

Total Aspen Heights HSA Contributions**

Allowed Employee HSA Contributions

Employee Only

$3,450

$1,000

$2,450 ($102.08 / pay period)

Employee + Spouse

$6,900

$1,500

$5,400 ($225 / pay period)

Employee + Child(ren)

$6,900

$1,500

$5,400 ($225 / pay period)

Family

$6,900

$2,000

$4,900 ($204.16 / pay period)

Coverage Tier

* Individuals 55 and over can contribute an additional $1,000 annually. * Employer HSA funding distributed per pay period.

14 ASPEN 2018 BENEFITS :: 371

An Idea - Try contributing the difference!

Traditional Copay Premium Per Paycheck

HDHP Premium Per Paycheck

Difference per Paycheck

Employee Only

$110.00

$20.00

$90.00

Employee + Spouse

$202.80

$37.50

$175.30

Employee + Child(ren)

$258.33

$27.50

$220.83

Family

$357.15

$50.00

$307.15 (MAX IS $204.16)

Coverage Tier

15 ASPEN 2018 BENEFITS :: 372

Annual Back-End HDHP Deductible Reimbursement Annual Employee Exposure/Out of Pocket

Employer “Back-End” HRA

Coverage Tier

Deductible

Company HSA Contribution

Employee Only

$5,000

$1,000

$2,000

$2,000

Employee + Spouse

$10,000

$1,500

$6,500

$2,000

Employee + Child(ren)

$10,000

$1,500

$6,500

$2,000

Family

$10,000

$2,000

$6,000

$2,000

16 ASPEN 2018 BENEFITS :: 373

Doing The Math: Example Traditional Copay Plan Cost (Employee + Family/In Network)

Employee Annual Premium

$8,571.60 ($714.30 per month)

Maximum Plan Out of Pocket Medical- Worst Case

$10,200

Maximum Out of Pocket Pharmacy – Worst Case

$3,000

Total Premium and Out of Pocket –Worst Case Less Employer Back-End Deductible Reimbursement

Total Out of Pocket

$21,771.60 $0 $21,771.60

17 ASPEN 2018 BENEFITS :: 374

Doing The Math: Example HDHP Plan Costs (Employee + Family/In Network)

Employee Annual Premium

$1,200 ($100 per month)

Maximum Plan Out of Pocket – Worst Case

$10,000

Total Premium and Out of Pocket – Worst Case

$11,200

Less Employer HSA Contribution

($2,000)

Less Back-End Deductible Reimbursement

($2,000)

Total Out of Pocket

$7,200

18 ASPEN 2018 BENEFITS :: 375

Tango – HSA Administrator

• Enrollment E-Mail From HR • Automatic upon enrollment in HDHP • HSA Account Management • Contribution Elections • Change Payroll Deduction • Reimbursement Tracking • Receipt Storage • “Pay Yourself Back” • Auto-Fill Transactions

19 ASPEN 2018 BENEFITS :: 376

ADP Flexible Spending Account (FSA) • Medical - $2,650 • Election immediately available • You can not have this plan if you have an HSA • Dependent Care - $5,000 • Account balance is the amount available • Working or full-time student • Licensed caretaker or facility • No health plan participation necessary • You CAN have this plan if you have an HSA 20 ASPEN 2018 BENEFITS :: 377

First Stop Health

NEW!!

First Stop Health - Telemedicine

•

FREE to access 24/7/365 toll-free telephonic/video/online access to doctors for routine services and prescriptions “Frictionless” access- No required up-front registration Generally less than 5 minute wait time Saves you time and money

• • • • •

• Common reasons to call First Stop Health • • • • • • •

Infections or rashes Sinus or allergy-related problems Sore throat and cough Colds and flu Swelling and/or soreness Nausea and/or vomiting; and Other minor illnesses and injuries

• 888-691-7867 • First Stop Health also has an app available and can be accessed at fshealth.com CLS Partners Confidential

21 ASPEN 2018 BENEFITS :: 378

Access the Right Care at the Right Time Care Center First Stop Health

Doctor’s Office PCP or Specialist

Why? You need convenient care for a common condition • 24/7 telephonic access

You need routine care or treatment for a current health issue.

Your primary doctor knows you and your health history and can • access your medical records • provide preventive and routine care • manage your medications • refer you to a specialist, if necessary

Convenience Care Clinic

Examples

Cost/Time

• • • • • •

cold or flu sinus infections poison ivy respiratory conditions pink eye urinary tract infections

• •

• • • •

Routine checkups Immunizations Preventive services Manage your general health

•

•

• • •

You can’t get to your doctor’s office, but your condition is not urgent or an emergency.

•

Convenience care clinics are often located in malls or retail stores offering services for minor health conditions. Staffed by nurse practitioners and physician assistants.

• • • • •

Common infections • strep throat Minor skin conditions • poison ivy Flu shots Pregnancy tests Minor cuts Ear aches

• • •

$0 copayment No appointment needed phone, or mobile app Average appointment wait >5 minutes

$25 PCP/Specialist copayment for Traditional Copay Plans Approx. $75-$200 HDHP Normally requires an appointment Little wait time with scheduled appointment $25 copayment Traditional Copay plans Approx. $80 HDHP Walk in patients welcome, no appointments necessary, wait times can vary

22 ASPEN 2018 BENEFITS :: 379

Access the Right Care at the Right Time Care Center Urgent Care

Why? You may need care quickly, but it is not an emergency, and your primary physician may not be available.

• • •

Urgent care centers offer treatment for non-life threatening injuries or illnesses.

Staffed by qualified physicians.

Emergency Room

You need immediate treatment of a very serious or critical condition.

The ER is for the treatment of life-threatening or very serious conditions that require immediate medical attention.

Do not ignore an emergency. If a situation seems life threatening, take action.

Call 911 or your local emergency number right away.

Cost/Time

Examples

• •

• • • • • • • • • •

Sprains Strains Minor broken bones • Fracture • Broken finger Minor infections Minor burns

•

Heavy bleeding Large open wounds Sudden change in vision Chest pain Sudden weakness or trouble talking Major burns Spinal injuries Severe head injury Difficulty breathing Major broken bones

•

• • •

• •

$50 copayment traditional copay plans Approx. $150 HDHP Higher cost than an office visit Walk in patients welcome, waiting periods may be longer as patients with more urgent needs will be treated first

Much more expensive (usually in the thousands of dollars) than the previously discussed providers Open 24/7, waiting periods may be longer Patients with lifethreatening emergencies will be treated first

23 ASPEN 2018 BENEFITS :: 380

How Do I Search for a Network Provider?

Visit www.bcbstx.com and Blue Mobile

Blue Choice PPO (BCA) Network 24 ASPEN 2018 BENEFITS :: 381

Blue Cross Wellness - More Info to Come!

NEW!!

You can earn Blue Points worth up to $250 by completing Wellness activities with Blue Cross!

• Use the Well OnTarget

platform found in Blue Access for Members • To earn points, you can: • Complete your Health Assessment • Complete self-directed courses • Sign up for the fitness program and log workouts • Sync a fitness device or app

25 ASPEN 2018 BENEFITS :: 382

MetLife â&#x20AC;&#x201C; Dental Plans Services

Dental Plan 1 (Best if using In-Network Providers)

Dental Plan 2 (Best if using Out-of-Network Providers)

$50 Individual & $150 Family

$50 Individual & $150 Family

$1,750 per covered person

$1,750 per covered person

Lifetime Orthodontia Maximum

$1,500

$1,500

Preventive Services

100%

100%

Basic Services

100% after deductible

80% after deductible

Major Services

60% after deductible

50% after deductible

Orthodontia (Adult & Child)

50%

50%

Negotiated Fee/MAC

90th R&C

Deductible Annual Maximum

Out of Network Reimbursement

26 ASPEN 2018 BENEFITS :: 383

MetLife â&#x20AC;&#x201C; Vision Plan Services

In-Network (VSP)

Out-of-Network

Exam

$10 copay

Covered up to $45

Materials

$25 copay

Single Vision

100%

Covered up to $30

Bifocal

100%

Covered up to $50

Trifocal

100%

Covered up to $65

Frames

$130 allowance, then 20% discount over balance

Covered up to $70

Contacts

$130 allowance

Covered up to $105

100%

Covered up to $210

Medically Necessary Frequency

12 month exam / 12 month lenses / 24 month frames

â&#x20AC;˘Contact lenses are in lieu of frames and lenses.

27 ASPEN 2018 BENEFITS :: 384

Life and Disability Enhancements!

NEW!!

• Aspen Heights is paying for 100% of a new short-term disability

program for all full-time employees!

• Aspen Heights is moving from MetLife to Liberty Mutual for our life and disability coverage • Liberty Mutual is allowing for a ONE-TIME true open enrollment for current employees • The Guaranteed Issue amount has been raised from $100,000 to $150,000

28 ASPEN 2018 BENEFITS :: 385

100% ASPEN HEIGHTS-PAID Short Term Disability NEW!!

• Aspen Heights will now cover all full-time

employees with Short Term Disability at no cost to you!

• Benefits begin on 15th day of injury or Sickness • Pays 60% of weekly earnings • Maximum benefit of $2,000 per week • Maximum benefit duration of the end of the 13th week of disability

29 ASPEN 2018 BENEFITS :: 386

Liberty Mutual – Voluntary LTD Plans • 90 day elimination period • Pays 60% of monthly earnings • Maximum benefit of $7,500 per month • 2 year own occupation • Benefits up to SSNRA • 12/12 pre-ex • 25% participation required • Can only be added at this time without EOI

30 ASPEN 2018 BENEFITS :: 387

Liberty Mutual - Life & AD&D Plans Group Term Life AD&D

• 1 x Annual Salary, to a

Maximum of $50,000

Voluntary Term Life AD&D NEW! Open Enrollment • Employee • $10K Increments • Up to Lesser of 5x Salary or $500,000 • NEW! $150,000 Guarantee Issue

• Guarantee Issue

• Spouse • $5K Increments • Up to $250,000, Not to Exceed 50% of Employee’s Amount • $50,000 Guarantee Issue

• Provided at no cost to you

• Child(ren) • 2 options: $5k or $10k • Not to exceed spouse’s benefit

• Includes AD&D

by Aspen Heights *EOI required for amounts over GI or for any amount elected outside of the initial eligibility period. *Liberty Mutual will cover all current elections if re-elected for 2018. *Spouse premium based on employee’s age.

31 ASPEN 2018 BENEFITS :: 388

Aspen Heights Parental Leave Benefit Aspen Heights offers a highly competitive parental leave program designed to promote true work-life balance.

• If you are giving birth, you are eligible for 8 weeks of paid

leave at 100% of pre-disability earnings • If you are not giving birth, you are eligible for 3 weeks of paid leave at your current earnings at the time of your leave • Remember that FMLA still applies, so if eligible, you may be eligible for additional, unpaid leave • Short Term Disability Integration- With our new short-term disability program, employees giving birth can expect to see their 8 weeks of paid leave paid through a mix of salary continuance and short-term disability benefits (which as mentioned previously, are 100% covered by Aspen Heights) 32 ASPEN 2018 BENEFITS :: 389

Employee Assistance Programs (EAPs) MyLibertyAssist + ADP Lifecare MyLibertyAssist- Available to you and all your immediate family members! Free to access as many times as you want!

Counseling- 5 FREE Face-to-Face Consultations per Year Financial Advice- One FREE telephonic session and worksheet review How Accesscare?

Care? do II access How Do • MyLibertyAssist

Consultation Areas • Financial Services • Childcare and Eldercare Assistance • Adoption and Education Assistance • Legal Services • Work-Life Services • Emotional Wellbeing

• Online: bensingerdupont.com/MLA

• Password: MLASSIST • Telephone: 877-695-2789 (877-

MYLBRTY) • ADP Lifecare • ADP Portal • Once registered: http://member.lifecare.com • Phone • 1-800-697-7315

33 ASPEN 2018 BENEFITS :: 390

Liberty Mutual- Life Services Website

NEW!!

Liberty Mutual Insurance offers additional services with valuable information on: • funeral planning • identity theft • grief and loss • wellness • legal and financial planning, and • online Will preparation • You can access the website by visiting

www.BDAlifeservices.com • Username: MLLIFE

34 ASPEN 2018 BENEFITS :: 391

401(k) • Eligible to enroll on the 1st day of your 7th month • Employer Match – 50% of the first 6% • Your election can be any combination of regular and/or Roth

401(k) • On your first anniversary you will be 50% vested in your

employer match • On your second anniversary you will be 100% vested in your employer match

www.mykplan.com or call 1-800-695-7526 35 ASPEN 2018 BENEFITS :: 392

Things to Remember • Open Enrollment Elections via ADP Portal at

https://workforcenow.adp.com • ADP Portal Closes Wednesday, November 15th at 6

pm CST! • Remember to actively enroll in: • Voluntary Life and AD&D • Voluntary Long Term Disability

• Please also update your H.S.A. election if you elect

the HDHP 36 ASPEN 2018 BENEFITS :: 393

Have questions?

Call ADP benefits support and technical assistance team for:

Call CLS Partners’ fabulous benefit support team for:

• ADP Login Challenges • Updating Dependents and

• Questions about coverage • Questions about pricing • Questions about plan

Beneficiaries • Technical assistance of all kinds • Confirmation of election submission • Contact Info:

comparison • Contact Info: • 877-306-9305 or • Support@CLSPartners.com

• 855-205-0566

*If you have any other questions or deep thoughts on interesting topics, come find Sarah Weiner in the HR Office or call/email.

37 ASPEN 2018 BENEFITS :: 394