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BURLESON ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2016 - 8/31/2017 www.mybenefitshub.com/burlesonisd

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Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS Medical and Scott & White HMO HSA Bank Health Savings Account (HSA) MDLIVE Telehealth Cigna Dental Superior Vision Aetna Long Term Disability APL Cancer UNUM Life and AD&D ID Watchdog Identity Theft NBS Flexible Spending Account (FSA)

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3 4-5 6-11 6 7 8 9 10

FLIP TO... PG. 4 HOW TO ENROLL

11 12-17 18-21 22-23 24-31 32-33 34-39 40-43 44-47 48-49 50-53

PG. 6 YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 12 YOUR BENEFITS PACKAGE


Benefit Contact Information

Benefit Contact Information BURLESON ISD BENEFITS

TELEHEALTH

LIFE AND AD&D

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/burlesonisd

MDLIVE (888) 365-1663 www.consultmdlive.com

UNUM (800) 583-6908 www.unum.com

BURLESON ISD BENEFITS OFFICE

DENTAL

IDENTITY THEFT

(817) 245-1046 www.burlesonisd.net

Cigna (800) 244-6224 www.mycigna.com

ID Watchdog (866) 513-1518 www.idwatchdog.com

TRS ACTIVECARE MEDICAL

VISION

FLEXIBLE SPENDING ACCOUNT

Aetna (800) 222-9205 www.trsactivecareaetna.com

Superior Vision (800) 507-3800 www.superiorvision.com

National Benefit Services (800) 274-0503 www.nbsbenefits.com

TRS HMO MEDICAL

DISABILITY

FINANCIAL PLANNING - 403(B)

Scott & White (800) 321-7947 www.trs.swhp.org

Aetna (800) 583-6908 File a claim: (888) 266-2917 www.aetna.com

National Benefit Services (800) 274-0503 www.nbsbenefits.com

HEALTH SAVINGS ACCOUNT

CANCER

HSA Bank (800) 357-6246 www.hsabank.com

American Public Life (800) 256-8606 www.ampublic.com

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How to Enroll On Your Device Enrolling in your benefits just got a lot easier! Text “burlesonisd” to 313131 to receive everything you

TEXT

need to complete your enrollment.

“burlesonisd”

TO

Avoid typing long URLs and scan directly to your benefits website,

313131

to access plan information, benefit guide, benefit videos, and more!

TRY ME

SCAN:

On Your Computer Access the Burleson ISD Benefits

Our online benefit enrollment

website from your computer, tablet

platform provides a simple and

or smartphone!

easy to navigate process. Enroll at your own pace, whether at home or at work. www.mybenefitshub.com/ burlesonisd delivers important benefit information with 24/7 access, as well as detailed plan information, rates and product videos.

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Open Enrollment Tip For your User ID: If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

Login Steps OR SCAN

1

Go to:

2

Click Login

3

Enter Username & Password

www.mybenefitshub.com/burlesonisd

All login credentials have been RESET to the default described below:

Username:

GO

LOGIN

Sample Username

lincola1234 Sample Password

The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

lincoln1234

If you have six (6) or less characters in your last name,

If you have trouble

use your full last name, followed by the first letter of

logging in, click on the

your first name, followed by the last four (4) digits of

“Login Help Video”

your Social Security Number.

for assistance.

Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.

Click on “Enrollment Instructions” for more information about how to enroll. 5


Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

Benefit elections will become effective 9/01/2016  (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event and changes must be made within 30  days of event. Online Benefit Access: www.mybenefitshub.com/ burlesonisd. You have access to benefit information 24/7 on the employee benefit provided. You can review and print the consolidated enrollment form or benefit guide, download claim forms and website plan summaries, links to carrier websites and provider searches.

Good News! Unum Voluntary Life will allow employees/ spouses to increase existing life insurance coverage all  the way up to guarantee issue without evidence of insurability.

Superior Vison plan will have a not plan changes, but will have a slight rate increase effective 9/1/16. Superior Vision now offering glasses and contacts purchase online at www.superiorvision.com. Medical Flexible spending annual maximum will increase to $2550 effective 9/1/16. Please remember you MUST login on the online enrollment system each year during annual enrollment to re-elect your flex amount. Existing cards will be funded by mid September. New participants will receive cards midlate September at the address provided during enrollment in THEbenefitsHUB. Please remember to review your beneficiaries each year as there could be a need for updates and/or changes. Due to the Affordable Care Act (ACA), every employee is required to login and complete the enrollment process, even if you are declining benefits.

Cigna Dental PPO & DHMO plans will have no plan changes, but will have a slight rate increase effective 9/1/16.

Login and complete your benefit enrollment from 08/01/2016 - 08/22/2016

Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 between 8am – 5pm CST

Update your profile information: home address, phone numbers, email, beneficiaries

REQUIRED: Provide correct dependent social security numbers

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SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year. CHANGES IN STATUS (CIS):

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS

Marital Status

A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in Status of Employment Affecting Coverage Eligibility

Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage. Eligibility for Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Government Programs

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SUMMARY PAGES

Annual Enrollment During your annual enrollment period, you have the opportunity

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website:

annual enrollment) unless a Section 125 qualifying event occurs.

www.mybenefitshub.com/burlesonisd. Click on the benefit plan you need information on (i.e., Dental) and you can find

Changes, additions or drops may be made only during the

the forms you need under the Benefits and Forms section.

annual enrollment period without a qualifying event. How can I find a Network Provider?

 Employees must review their personal information and verify that dependents they wish to provide coverage for are

district’s benefit website:

included in the dependent profile. Additionally, you must

www.mybenefitshub.com/burlesonisd. Click on the benefit

notify your employer of any discrepancy in personal and/or

plan you need information on (i.e., Dental) and you can find

benefit information.

For benefit summaries and claim forms, go to your school

Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.

provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 30 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

date for new benefits to be effective, meaning you are physically

covered by married spouses within the BURLESON ISD or as

capable of performing the functions of your job on the first day of

both employees and dependents.

work concurrent with the plan effective date. For example, if your 2016 benefits become effective on September 1, 2016, you must be actively-at-work on September 1, 2016 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

CONTINUATION

Medical

Aetna

To 26

COBRA (AETNA or Scott & White)

Dental

Cigna

To 26

COBRA (NBS)

Vision

Superior Vision

To 26

COBRA (NBS)

Voluntary Life

Unum

Unmarried To 26

Portable within 30 days of termination

Cancer

American Public Life

To 26

Portable within 30 days of termination if coverage in force 12 months

Telehealth

MDLIVE

Unmarried to 26

Direct Pay option within 30 days of termination

Medical Flex

National Benefit Services

To 26

COBRA (NBS)

12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes

N/A

Dependent Flex

National Benefit Services

Health Savings Account

HSA Bank

Tax Dependent

Contact HSA Bank

Identity Theft

ID Watchdog

Unmarried to 26

Direct Pay option within 30 days of termination

If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.

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Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

on a full-time basis, either at one of the employer’s usual

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2016 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.

Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.

Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.

Plan Year September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services

Calendar Year January 1st through December 31st

Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

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(including diagnostic and/or consultation services).


SUMMARY PAGES

HSA vs. FSA Health Savings Account (HSA) (IRC Sec. 223)

Flexible Spending Account (FSA) (IRC Sec. 125)

Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.

Allows employees to pay out-of-pocket expenses for copays, deductibles and certain services not covered by medical plan, tax-free. This also allows employees to pay for qualifying dependent care taxfree.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Cash-Outs of Unused Amounts (if no medical expenses)

$1,300 single (2016) $2,600 family (2016) $3,350 single (2016) $6,750 family (2016) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty. Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

Year-to-year rollover of account balance?

Yes, will roll over to use for subsequent year’s health coverage.

No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?

Yes

No

Portable?

Yes, portable year-to-year and between jobs.

No

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

N/A Varies per employer Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC). Not permitted

FLIP TO… PG. 18

FLIP TO… PG. 50

FOR HSA INFORMATION

FOR FSA INFORMATION

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AETNA

Medical

YOUR BENEFITS PACKAGE

About this Benefit Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.

DID YOU KNOW?

More than 70% of adults across the United States are already being diagnosed with a chronic disease.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 12


2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits* Type of Service

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

Out-of-Pocket Maximum (per plan year; does include medical deductible/ any medical copays/coinsurance/ any prescription drug deductible and applicable copays/coinsurance)

$6,550 individual $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual)

$6,850 individual $13,700 family

$6,850 individual $13,700 family

Coinsurance Plan pays (up to allowable amount) Participant pays (after deductible)

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Preventive Care See next page for a list of services

Plan pays 100%

Plan pays 100%

Plan pays 100%

Teladoc® Physician Services

$40 consultation fee (applies to deductible and out-of-pocket maximum)

Plan pays 100%

Plan pays 100%

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays

20% after deductible

$100 copay plus 20% after deductible

$100 copay plus 20% after deductible

Inpatient Hospital (preauthorization required) (facility charges) Participant pays

20% after deductible

$150 copay per day plus 20% after deductible ($750 maximum copay per admission)

$150 copay per day plus 20% after deductible($750 maximum copay per admission; $2,250 maximum copay per plan year)

Emergency Room (true emergency use) Participant pays

20% after deductible

$150 copay plus 20% after deductible (copay waived if admitted)

$150 copay plus 20% after deductible (copay waived if admitted)

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

$150 copay per visit plus 20% after deductible

Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays

$5,000 copay plus 20% after deductible

Not covered

$5,000 copay (does not apply to out -of-pocket maximum) plus 20% after deductible

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

$0 for generic drugs $200 per person for brand-name drugs

$0 for generic drugs $200 per person for brand-name drugs

Retail Short-Term (up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $20 $40** 50% coinsurance**

$20 $40** $65**

Retail Maintenance (after first fill; up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $35 $60** 50% coinsurance**

$35 $60** $90**

Mail Order and Retail-Plus (up to a 90-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $45 $105*** 50% coinsurance

$45 $105*** $180***

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

$200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply)

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.

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2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits* TRS-ActiveCare Plans—Preventive Care Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

Preventive Care Services

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www.uspreventiveservicestaskforce.org/Page/Name/uspstf-aand-b-recommendations Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved. Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/facts-and-features/fact-sheets/ preventive-services-covered-under-aca/#CoveredPreventive ServicesforAdults For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. (Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.

Plan pays 100% (deductible waived)

Plan pays 100% (deductible waived; no copay required)

Plan pays 100% (deductible waived; no copay required)

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling – 8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support – 6 lactation counseling visits per 12 months

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling – 8 visits per 12 months  Healthy diet/obesity counseling –unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support – 6 lactation counseling visits per 12 months

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening –1 per year age 50 and over  Smoking cessation counseling –8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support –6 lactation counseling visits per 12 months

Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800222-9205. The list may change as FDA guidelines are modified. Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

After deductible, plan pays 80%; $60 copay for specialist participant pays 20%

$50 copay for specialist

Annual Hearing Examination Participant pays

After deductible, plan pays 80%; participant pays 20%

$30 copay for primary $50 copay for specialist

$30 copay for primary $60 copay for specialist

Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug 14benefits are administered by Caremark.


2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services

Copay

Preventive Services

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions

Copay

Annual Deductible

$1,000 Individual/ $3,000 Family

Annual out-of-pocket maximum (including medical and prescription co-pays and coinsurance)

Lifetime Paid Benefit Maximum

Outpatient Services

$5,000 Individual/ $10,000 Family (includes combined Medical and RX copays, deductibles and coinsurance)

None

Copay $20 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections

No Charge 20% after deductible

Outpatient Surgery

$150 co-pay and 20% of charges after deductible

Maternity Care

Copay

Prenatal Care

No Charge $150 per day4 and 20% of charges after deductible

Inpatient Delivery

Inpatient Services

Copay

Overnight hospital stay: includes all medical services including semi -private room or intensive care

Diagnostic & Therapeutic Services Physical and Speech Therapy 5

Manipulative Therapy

Equipment and Supplies

$150 per day4 and 20% of charges after deductible

Copay $50 copay 20% without office visit $40 plus 20% with office visit

Copay

Preferred Diabetic Supplies and Equipment

$3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment

30% after Rx deductible

Durable Medical Equipment/ Prosthetics

20% after deductible

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2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services

Copay

Home Health Care Visit

$50 co-pay

Worldwide Emergency Care

Copay

Nurse Advice Line

1-877-505-7947

Online Services

No Charge — go to www.trs.swhp.org

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$100

Does not apply to preferred generic drugs

Ask an SWHP Pharmacy representative how to save money on your prescriptions.

Maintenance Quantity

Retail Quantity (Up to a 30-day supply)

BSWH Pharmacies Only (Up to a 90-day supply)

$3 copay

$6 copay

Preferred Brand

30% after Rx deductible

30% after Rx deductible

Non-preferred

50% after Rx deductible

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after deductible

Not available

Preferred Generic7

Mail Order

Specialty Medications (Up to a 30-day supply)

1-800-707-3477

Copay 20% after Rx deductible

1

Including all services billed with office visit Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after deductible 5 5 visits max per month, 35 max visit per year 6 Copay waived if admitted within 24 hours 7 If a brand name drug is dispensed when a generic is available, 50% copay applies 2

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Burleson ISD 2016 - 2017 TRS Premiums and District Contributions Total Cost of Benefit

District Pays

Employee Pays

Employee Only

$341.00

$235.00

$106.00

Employee/Spouse

$914.00

$235.00

$679.00

Employee/Child(ren)

$615.00

$235.00

$380.00

$1,231.00

$235.00

$996.00

$484.00

$235.00

$249.00

$1,147.00

$235.00

$912.00

$779.00

$235.00

$544.00

$1,361.00

$235.00

$1,126.00

$645.00

$235.00

$410.00

Employee/Spouse

$1,552.00

$235.00

$1,317.00

Employee/Child(ren)

$1,042.00

$235.00

$807.00

Employee/Family

$1,597.00

$235.00

$1,362.00

$530.16

$235.00

$295.16

$1,192.82

$235.00

$957.82

$839.16

$235.00

$604.16

$1,322.98

$235.00

$1,087.98

TRS Active Care 1 - HD

Employee/Family

TRS Active Care Select Employee Only Employee/Spouse Employee/Child(ren) Employee/Family

TRS Active Care 2 Employee Only

TRS HMO Scott & White Employee Only Employee/Spouse Employee/Child(ren) Employee/Family

17


HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

About this Benefit A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.

DID YOU KNOW? The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 18


HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. You can not participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 

A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds

Medicare mid-year, catch-up contributions should be prorated) Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the Burleson ISD website at www.mybenefitshub.com/burlesonisd

HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com

Debit Card  You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements.  You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder  Age 55 or older (regardless of when in the year an accountholder turns 55)  Not enrolled in Medicare (if an accountholder enrolls in

19


How the HSA Plan Works A Health Savings Account (HSA) is an individually-owned, taxadvantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through selfdirected investment options1.

How an HSA works:

 

You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well. You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings. Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes). Check balances and account information via HSA Bank’s Internet Banking 24/7.

Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally:  You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B.  You cannot be covered by TriCare.  You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA).  You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).  You must be covered by the qualified HDHP on the first day of the month. When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2.

20

2016 Annual HSA Contribution Limits Individual = $3,350 Family = $6,750

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catchup contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how:  Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible.  HSA funds earn interest and investment earnings are tax free.  When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always taxfree. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.


How the HSA Plan Works Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRSqualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs

Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays

For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

21


MDLIVE YOUR BENEFITS PACKAGE

Telehealth

About this Benefit Telehealth provides 24/7/365 access to boardcertified doctors via telephone consultations who can diagnose, recommend treatment and prescribe medication. Whether you are at home, traveling or at work, Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.

DID YOU KNOW?

75%

of all doctor, urgent care, and ER visits could be handled safely and effectively via telehealth.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 22


Telehealth When should I use MDLIVE?

 If you’re considering the ER or urgent care for a nonemergency medical issue  Your primary care physician is not available  At home, traveling, or at work  24/7/365, even holidays!

What can be treated?         

Allergies Asthma Bronchitis Cold and Flu Ear Infections Joint Aches and Pain Respiratory Infection Sinus Problems And More!

Pediatric Care related to:       

Cold & Flu Constipation Ear Infection Fever Nausea & Vomiting Pink Eye And More!

Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.

How much does it cost? $7.00 Voluntary One cost covers entire family with unlimited free phone consultations.

Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp     

Access to a doctor anywhere: at home, at work, or on the go Choose doctors from one of the nation's largest telehealth networks Available 24/7 by video or phone Private, secure and confidential visits Connect instantly with MDLIVE Assist

Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.

Scan with your smartphone to get the app.

Call us at (888) 365-1663 or visit us at www.consultmdlive.com

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

23


CIGNA

Dental

YOUR BENEFITS PACKAGE

About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.

DID YOU KNOW?

Good dental care may improve your overall health. Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 24


Dental PPO - High Option Benefits Network Calendar Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Emergency Care to Relieve Pain Fluoride Application Class II - Basic Restorative Care Fillings Sealants Non- Routine X-Rays Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions Class III - Major Restorative Care Crowns Space Maintainers Histopathologic Exams Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Class IV - Orthodontia Lifetime Maximum

Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $1,500

$1,500

$50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50%*

50%*

50%*

50%

50% $1,000 Dependent children to age 19

50%

50% $1,000 Dependent children to age 19

Monthly PPO Premiums Tier

Rate

EE Only

$37.98

EE + Spouse

$84.48

EE + Child(ren)

$93.77

Family Coverage

$130.26

Dependent/Student age limitation 26/26. Dental Network Savings Program (DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. 25


Dental PPO - Low Option Benefits Network Calendar Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Emergency Care to Relieve Pain Fluoride Application Class II - Basic Restorative Care Fillings Sealants Non-Routine X-Rays Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions Class III - Major Restorative Care Crowns Space Maintainers Histopathologic Exams Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays

Class IV - Orthodontia

Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $1,000

$1,000

$50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

80%

20%

80%

20%

60%*

40%*

60%*

40%*

40%*

60%*

40%*

60%*

Not covered

100% of your dentist’s usual fees

Not covered

100% of your dentist’s usual fees

Monthly PPO Premiums Tier

Rate

EE Only

$21.74

EE + Spouse

$47.04

EE + Child(ren)

$49.89

Family Coverage

$75.47

Dependent/Student age limitation 26/26. Dental Network Savings Program (DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. 26


Dental PPO - High and Low Options Procedure

Exclusions and Limitations

Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Sealants Space Maintainers Prosthesis Over Implant

50% coverage on Class III and IV for 24 months Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Various limits per Calendar year depending on specific test Bitewings: 2 per Calendar year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions

    

                   

Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

27


Dental - DHMO What You’ll Pay Sampling of covered procedures

Cost with Cigna Dental Care

Estimated cost without dental coverage

$0

$70–$136 each

$0

$53–$102 each

$0 $0

$40–$76 $62–$118

$0

$28–$53

$0 $0 $16 $28 $33 $595

$33–$63 $84–$161 $42–$80 $118–$226 $120–$231 $852–$1,640

$515

$1,042–$2,005

$135 $93 $64 $300 $480

$179–$344 $109–$209 $120–$231 $370–$712 $849–$1,634

$780

$1,097–$2,112

$360

$640–$1,233

Adult cleaning (two per calendar year each at $0) (additional cleanings available at $45 each) Child cleaning (two per calendar year each at $0) (additional cleanings available at $30 each) Periodic oral evaluation Comprehensive oral evaluation Topical fluoride (two per calendar year each at $0) (additional topical fluoride available at $15 each) X–rays – (bitewings) 2 films X–rays – panoramic film Sealant – per tooth Amalgam filling (silver colored) – 2 surfaces Composite filling (tooth–colored) – 1 surface, Anterior Molar root canal (excluding final restoration) Comprehensive orthodontics – child (up to 19th birthday) – Banding Periodontal (gum) scaling & root planing – 1 quadrant Periodontal (gum) maintenance Removal/extraction of erupted tooth Removal/extraction of impacted tooth Crown – porcelain fused to high noble metal Implant supported retainer for porcelain fused to metal fixed partial denture Occlusal Guard - By Report (Limit 1 per 24 Months)

Monthly DHMO Premiums

Procedure

Limit

Exams

Two per calendar year

X-rays (routine)

Bitewings: 2 per calendar year

EE Only

$9.33

X-rays (non-routine)

Full mouth: 1 every 3 calendar years Panorex: 1 every 3 calendar years

EE + Spouse

$15.12

EE + Child(ren)

$20.91

Crowns and inlays

Replacement every 5 years

Family Coverage

$24.92

Bridges

Replacement every 5 years

Dentures and partials

Replacement every 5 years

Finding a network dentist is easy.

Relines, rebases

One every 36 months

Adjustments

Four within the first 6 months after installation

There are several ways to choose your network general dentist:

Prosthesis over implant

Replacement every 5 years if unserviceable and cannot be repaired

Temporomandibular Joint (TMJ) treatment

One occlusal orthotic device per 24 months

Athletic mouth guard

One athletic mouth guard per 12 months when listed on your PCS

28

Tier

Rate

 Find a dentist at www.cigna.com. Our online dental directory is up‐ dated weekly.  Call 1.800.Cigna24 (1.800.244.6224) to speak with a customer service representative. Our representatives can send you a customized dental directory listing via email.


Dental - DHMO Under your plan, you have coverage for hundreds of dental procedures. This overview shows you a small sampling of covered services and what you will pay compared to your estimated cost without coverage.

Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility at the dentist’s usual fees. There is no coverage for:

Review your plan materials to understand how your plan works.  For questions on the plan before enrollment, call 1.800.Cigna24 (1.800.244.6224) and select the “Enrollment Information”  prompt.

Or in connection with an injury arising out of, or in the course of, any employment for wage or profit Charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States government or by a state or municipal government if the person had no insurance

Key plan features 

There is a $5 office visit fee associated with your plan.

No deductibles – you don’t have to reach a certain level of out-of-pocket expenses before your insurance kicks in.

No dollar maximums – you don’t have to worry about your coverage running out after your covered expenses reach a certain dollar amount.

Easy to understand plan – the fees you pay your dentist are clearly listed on your Patient Charge Schedule (PCS).

To the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received 

The charges which the person is not legally required to pay

Charges which would not have been made if the person had no insurance

Due to injuries which are intentionally self-inflicted

Services not listed on the PCS

Services provided by a non-network dentist without Cigna Dental’s prior approval (except emergencies, as described in your plan documents)

There are no claim forms to fill and no waiting periods for coverage.

The network general dentist you choose will manage your overall dental care.

Covered family members can choose their own network general dentists – near home, work or school.

You don’t need a referral for children under seven to visit a network pediatric dentist. And you don’t need a referral to see a network orthodontist.

Services related to an injury or illness paid under workers’ compensation, occupational disease or similar laws

Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid

Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war

Services performed primarily for cosmetic reasons unless specifically listed on your PCS

General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS

Prescription medications

Replacement of filled and/or removable appliances (including filled and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect

Surgical implant of any type unless specifically listed on your PCS

Services considered to be unnecessary or experimental

There’s no age limit on sealants, which help prevent tooth decay.

Your plan covers certain procedures to help detect oral cancer in its early stages.

24/7 access to the Dental Information Line—this line is staffed by trained professionals who can help you if you have questions about dental treatment and clinical symptoms.

Referrals are required for specialty care services. Specialty treatment plans require payment authorization for services to be covered under your plan, except for Pediatrics, Orthodontics and Endodontics. You should verify with your Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna before treatment begins.

29


Dental DHMO in nature or do not meet commonly accepted dental standards

The replacement of an occlusal guard (night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS

Services and supplies received from a hospital

The completion of crowns, bridges, dentures, or root canal treatment already in progress on the effective date of your Cigna Dental coverage

Crowns, bridges and/or implant supported prosthesis used solely for splinting

Resin bonded retainers and associated pontics

Procedures or appliances for minor tooth guidance or to control harmful habits

 

the replacement of congenitally missing teeth

The completion of implant supported prosthesis (including crowns, bridges and dentures) already in progress on the effective date of your Cigna Dental coverage, unless specifically listed on your PCS4

Key plan features 

There is a $5 office visit fee associated with your plan.

No deductibles – you don’t have to reach a certain level of out-of-pocket expenses before your insurance kicks in.

No dollar maximums – you don’t have to worry about your coverage running out after your covered expenses reach a certain dollar amount.

Consultations and/or evaluations associated with services that are not covered

Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor  or hopeless periodontal prognosis

Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS

Bone grafting and/or guided tissue regeneration when performed in conjunction with an apicoectomy or periradicular surgery

Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure

Services performed by a prosthodontist

Localized delivery of antimicrobial agents when performed alone or in the absence of traditional periodontal therapy

Infection control and/or sterilization

The recementation of any inlay, onlay, crown, post and core or filled bridge within 180 days of initial placement

There are no claim forms to fill and no waiting periods for coverage.

The network general dentist you choose will manage your overall dental care.

Covered family members can choose their own network general dentists – near home, work or school.

You don’t need a referral for children under seven to visit a network pediatric dentist. And you don’t need a referral to see a network orthodontist.

There’s no age limit on sealants, which help prevent tooth decay.

Your plan covers certain procedures to help detect oral cancer in its early stages.

Any localized delivery of antimicrobial agent procedures  when more than eight (8) of these procedures are reported on the same date of service.

Easy to understand plan – the fees you pay your dentist are clearly listed on your Patient Charge Schedule (PCS).

24/7 access to the Dental Information Line—this line is staffed by trained professionals who can help you if you have questions about dental treatment and clinical symptoms.

What’s covered

You can save money on a wide range of services, including: The recementation of any implant supported prosthesis (including crowns, bridges and dentures) within 180  Preventive care – cleanings, fluoride, sealants, bitewing days of initial placement X-rays, full mouth X-rays, and more Services to correct congenital malformations, including

30

Basic care – tooth-colored fillings (called resin or


Dental DHMO composite) and silver-colored fillings (called amalgam) 

Major services – crowns, bridges, and dentures (including those placed over implants), root canals, oral surgery, extractions, treatment for periodontal (gum) disease, and more.

Specialty care – at the same fee as general care, with an approved referral

Orthodontic care – braces for children and adults

General anesthesia – when medically necessary

Teeth whitening – using take home bleaching trays and gel

subsidiaries include Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries. Cigna DHMO plans are provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc.; Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, Cigna DHMO plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI.

Age and frequency limitations may apply to some covered services. Review the rest of your enrollment materials for more details

What’s not covered* Your dental plan covers services that can help you maintain a healthy mouth and treat or manage dental conditions. But no plan covers everything. Here are some examples of services not covered:  Services provided by a non-network dentist without prior approval from Cigna Dental (except emergencies)3 

Replacement of fixed or removable bridges, dentures and orthodontic retainers that are lost, stolen, or damaged due to patient abuse, misuse or neglect

Cosmetic dentistry unless specifically listed on your PCS

Dental implant surgery or services associated with placement, repair removal, or restoration of a dental implant

*This is not a complete list. For a complete list of services not covered, refer to the rest of your enrollment materials or call 1.800.Cigna24 (1.800.244.6224) if you have questions or need more information. 3

Minnesota and Oklahoma residents: See the enclosed brochure for information on your out of network coverage. The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. “Cigna” is a registered service mark and the “Tree of Life” logo, “GO YOU” and “Cigna Dental” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating

31


SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

About this Benefit Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.

DID YOU KNOW?

75% of U.S. residents between age 25 and 64 require some sort of vision correction.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 32


Vision Benefits Exam Frames Contact Lenses1

In-Network

Out-of-Network

Covered in full $150 retail allowance $175 retail allowance

Up to $35 retail Up to $70 retail Up to $80 retail

Covered in full

Up to $150 retail

Medically Necessary Contact Lenses Lasik Vision Correction

$200 allowance2

Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Lenticular

Covered in full Covered in full Covered in full See description3 Covered in full

Up to $25 retail Up to $40 retail Up to $45 retail Up to $45 retail Up to $80 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.

Monthly Premiums EE only EE + Spouse EE + Child(ren) EE + Family

$10.30 $17.58 $18.62 $27.30

Co-Pays Exam Materials

$10 $10

Services/Frequency Exam Frame Lenses Contact Lenses

12 months 12 months 12 months 12 months

(Based on date of service)

1

Contact lenses and related professional services (fitting, evaluation and followup) are covered in lieu of eyeglass lenses and frames benefit. 2 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

SuperiorVision.com Customer Service 800.507.3800

The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions 33


AETNA YOUR BENEFITS PACKAGE

Long Term Disability

About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.

DID YOU KNOW?

Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.

34.6 months is the duration of the average disability claim.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 34


Long Term Disability Eligibility

5 Year Reducing Benefit for Disability due to Sickness:

All active full time employees working 30 hours per week or more.

Age at Disability Less than age 65 Age 65 - 68 Age 69+

Purpose Long Term Disability insurance provides income replacement benefits for you and your family in the event you are unable to work due to an accident or sickness.

Maximizing Income Protection Long Term Disability (LTD) Insurance can offer an affordable way for educators and administrators to protect their lifestyles—and the people who depend upon them. Employees can choose from a selection of LTD features they feel best match their financial needs.  

Employees can choose their Monthly Benefit Amount in $100 increments, from $200 to $7,500 (not to exceed 66 2/3% of monthly earnings). Employees can choose from among six accident/sickness Benefit Waiting Periods. A benefit waiting period is the period of time in which an employee must be continuously disabled before you are eligible for benefits. Accident 0 Days 14 Days 30 Days 60 Days 90 Days 180 Days

Sickness 7 Days 14 Days 30 Days 60 Days 90 Days 180 Days

Maximum Benefit Period Plan A: ADEA II for Disability due to Injury and Sickness: Disabled less than age 60, benefits continue to end of the month age 65. Age at Disability Age 60 - 64 Age 65 - 68 Age 69+

Maximum Duration 60 months To age 70 12 months

Plan B: ADEA II for Disability due to Injury: Disabled less than age 60, benefits continue to end of the month age 65. Age at Disability Age 60 - 64 Age 65 - 68 Age 69+

Maximum Duration 5 years To age 70 1 year

Limitations & Exclusions Benefits for Mental/Nervous/Substance Abuse/Self-Reported Illnesses are limited to 12 months lifetime combined.

Pre-Existing Exclusion There is a 3/12 pre-existing conditions clause. This is a look back period to see if you were treatment-free for a 3-month period prior to the effective date of your coverage. If you weren’t treatment-free, the pre-existing condition is excluded from coverage if you’re disabled within 12-months of first becoming insured. In addition, if during an annual enrollment period you apply for additional benefits or select a shorter elimination period, this plan will not cover the increase in your coverage if you have a pre-existing condition.

Plan Features Maximum Benefit Employees can protect as much as $7,500 of their income as long as the benefit is not greater than 66 2/3% of their salary.

Definition of Disability 2 Year Own Occupation with Residual. Covers Non-Occupational and Occupational disabilities – not in lieu of Workers Compensation. During the Elimination Period and the Own Occupation Period – any day that an individual is unable to perform the material duties of his/her own occupation; or while unable to perform the material duties of his/her own occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 20% of their indexed pre-disability earnings due to a disable condition. After the Own Occupation Period – any day that an individual is unable to perform the material duties of any occupation for which he/she is or may become fitted, based on training, education or experience; or while unable to perform the material duties of any reasonable occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 40% of his/her pre-indexed earnings due to a disabling condition.

Maximum Duration 60 months To age 70 12 months 35


Long Term Disability 1st Day Hospital Benefit

Continuity of Coverage

This feature waives the waiting period if an insured is hospitalized. Hospitalized means that, if because of your disability, you are hospital confined as an inpatient, benefits begin the first day of inpatient confinement. Inpatient means you are confined to a hospital room due to your sickness or injury, for 24 or more consecutive hours. This benefit is included in the 0/7, 14/14, and 30/30 waiting periods.

Insured individuals do not lose coverage due to an employer’s change in group insurance carriers.

12 Month Return-to-Work Incentive This benefit gives an employee the opportunity to return to work part time earning some income plus receive LTD benefits allowing them to receive up to 100% income replacement during the first 12 months.

Deductible Income Income benefit sources payable to the employee, employee’s spouse, children and/or dependents due to the employee’s disability or retirement. Sources include, but are not limited to, benefits payable from: unemployment compensation, Workers’ Comp, statutory disability plans, veteran’s benefits, Assault Leave Benefits, and any other group or association disability or retirement plans. The following Income benefit sources have a 6 month deferral in which no offset will be applied. Employer provided sick leave or salary continuation, Auto Liability Insurance, Social Security, 3rd party liability, statutory disability plans or any other group or association disability. All other offsets are immediate.

Survivor Benefit Pays a lump sum equal to 3 times the non-integrated LTD benefit after 180 days of disability.

Waiver of Premium If you become disabled, your premium payment for your insurance will be waived on any premium due date on which: (1) You remain Disabled for 90 consecutive days; and (2) Disability Benefits are being paid or are payable for the Disability.

Rehabilitation Plan Benefit During the employee’s active participation in an Aetna Approved Rehab Program, Aetna will pay an additional 10% of the monthly benefit, after all applicable reductions for other income benefits, but not more than $500 per month. This incentive will be paid up to 6 consecutive months for each period of disability.

36

Minimum Benefit 10% of gross maximum Monthly Benefit or $100.

Education Benefit A benefit in the amount of $200 per month, per child, who is an eligible student.

Child/Dependent Care Included ‐ After 6 months of benefit are paid, a benefit is available to reimburse an employee for dependent care expenses while participating in an approved rehabilitation program. An amount of $350 per month per dependent to a maximum of $1,000 is payable for up to 24 months.

Worksite Modification Benefit This benefit allows Aetna to pay for expenses of worksite modifications that result in a disabled employee’s return to work.

EAP Enhanced EAP for LTD Insured members includes 3 fact to face counseling sessions for LTD covered members & their immediate household members per year and unlimited telephonic EAP consultations.

Social Security Assistance Assistance for eligible employees with the application process for Social Security disability benefits.

Late Entrant Employees who enroll for any contributory LTD coverage more than 60 days later than the date they are first eligible or elect to increase their coverage or who were previously declined for coverage are subject to the Pre‐ex rules.


Long Term Disability Plan A Accident/Sickness Benefit Waiting Period Monthly Cost

Burleson ISD Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

90/90

180/180

$3,600

$300

$200.00

$9.02

$7.20

$5.94

$4.06

$3.52

$2.72

$5,400

$450

$300.00

$13.53

$10.80

$8.91

$6.09

$5.28

$4.08

$7,200

$600

$400.00

$18.04

$14.40

$11.88

$8.12

$7.04

$5.44

$9,000

$750

$500.00

$22.55

$18.00

$14.85

$10.15

$8.80

$6.80

$10,800

$900

$600.00

$27.06

$21.60

$17.82

$12.18

$10.56

$8.16

$12,600

$1,050

$700.00

$31.57

$25.20

$20.79

$14.21

$12.32

$9.52

$14,400

$1,200

$800.00

$36.08

$28.80

$23.76

$16.24

$14.08

$10.88

$16,200

$1,350

$900.00

$40.59

$32.40

$26.73

$18.27

$15.84

$12.24

$18,000

$1,500

$1,000.00

$45.10

$36.00

$29.70

$20.30

$17.60

$13.60

$19,800

$1,650

$1,100.00

$49.61

$39.60

$32.67

$22.33

$19.36

$14.96

$21,600

$1,800

$1,200.00

$54.12

$43.20

$35.64

$24.36

$21.12

$16.32

$23,400

$1,950

$1,300.00

$58.63

$46.80

$38.61

$26.39

$22.88

$17.68

$25,200

$2,100

$1,400.00

$63.14

$50.40

$41.58

$28.42

$24.64

$19.04

$27,000

$2,250

$1,500.00

$67.65

$54.00

$44.55

$30.45

$26.40

$20.40

$28,800

$2,400

$1,600.00

$72.16

$57.60

$47.52

$32.48

$28.16

$21.76

$30,600

$2,550

$1,700.00

$76.67

$61.20

$50.49

$34.51

$29.92

$23.12

$32,400

$2,700

$1,800.00

$81.18

$64.80

$53.46

$36.54

$31.68

$24.48

$34,200

$2,850

$1,900.00

$85.69

$68.40

$56.43

$38.57

$33.44

$25.84

$36,000

$3,000

$2,000.00

$90.20

$72.00

$59.40

$40.60

$35.20

$27.20

$37,800

$3,150

$2,100.00

$94.71

$75.60

$62.37

$42.63

$36.96

$28.56

$39,600

$3,300

$2,200.00

$99.22

$79.20

$65.34

$44.66

$38.72

$29.92

$41,400

$3,450

$2,300.00

$103.73

$82.80

$68.31

$46.69

$40.48

$31.28

$43,200

$3,600

$2,400.00

$108.24

$86.40

$71.28

$48.72

$42.24

$32.64

$45,000

$3,750

$2,500.00

$112.75

$90.00

$74.25

$50.75

$44.00

$34.00

$46,800

$3,900

$2,600.00

$117.26

$93.60

$77.22

$52.78

$45.76

$35.36

$48,600

$4,050

$2,700.00

$121.77

$97.20

$80.19

$54.81

$47.52

$36.72

$50,400

$4,200

$2,800.00

$126.28

$100.80

$83.16

$56.84

$49.28

$38.08

$52,200

$4,350

$2,900.00

$130.79

$104.40

$86.13

$58.87

$51.04

$39.44

$54,000

$4,500

$3,000.00

$135.30

$108.00

$89.10

$60.90

$52.80

$40.80

$55,800

$4,650

$3,100.00

$139.81

$111.60

$92.07

$62.93

$54.56

$42.16

$57,600

$4,800

$3,200.00

$144.32

$115.20

$95.04

$64.96

$56.32

$43.52

$59,400

$4,950

$3,300.00

$148.83

$118.80

$98.01

$66.99

$58.08

$44.88

$61,200

$5,100

$3,400.00

$153.34

$122.40 $100.98

$69.02

$59.84

$46.24

$63,000

$5,250

$3,500.00

$157.85

$126.00 $103.95

$71.05

$61.60

$47.60

$64,800

$5,400

$3,600.00

$162.36

$129.60 $106.92

$73.08

$63.36

$48.96

$66,600

$5,550

$3,700.00

$166.87

$133.20 $109.89

$75.11

$65.12

$50.32

$68,400

$5,700

$3,800.00

$171.38

$136.80 $112.86

$77.14

$66.88

$51.68

$70,200

$5,850

$3,900.00

$175.89

$140.40 $115.83

$79.17

$68.64

$53.04 37


Long Term Disability Plan A Accident/Sickness Benefit Waiting Period Monthly Cost

Burleson ISD Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

$72,000

$6,000

$4,000.00

$180.40

$73,800

$6,150

$4,100.00

$75,600

$6,300

$77,400

60/60

90/90

180/180

$144.00 $118.80

$81.20

$70.40

$54.40

$184.91

$147.60 $121.77

$83.23

$72.16

$55.76

$4,200.00

$189.42

$151.20 $124.74

$85.26

$73.92

$57.12

$6,450

$4,300.00

$193.93

$154.80 $127.71

$87.29

$75.68

$58.48

$79,200

$6,600

$4,400.00

$198.44

$158.40 $130.68

$89.32

$77.44

$59.84

$81,000

$6,750

$4,500.00

$202.95

$162.00 $133.65

$91.35

$79.20

$61.20

30/30

$82,800

$6,900

$4,600.00

$207.46

$165.60 $136.62

$93.38

$80.96

$62.56

$84,600

$7,050

$4,700.00

$211.97

$169.20 $139.59

$95.41

$82.72

$63.92

$86,400

$7,200

$4,800.00

$216.48

$172.80 $142.56

$97.44

$84.48

$65.28

$88,200

$7,350

$4,900.00

$220.99

$176.40 $145.53

$99.47

$86.24

$66.64

$90,000

$7,500

$5,000.00

$225.50

$180.00 $148.50 $101.50

$88.00

$68.00

$91,800

$7,650

$5,100.00

$230.01

$183.60 $151.47 $103.53

$89.76

$69.36

$93,600

$7,800

$5,200.00

$234.52

$187.20 $154.44 $105.56

$91.52

$70.72

$95,400

$7,950

$5,300.00

$239.03

$190.80 $157.41 $107.59

$93.28

$72.08

$97,200

$8,100

$5,400.00

$243.54

$194.40 $160.38 $109.62

$95.04

$73.44

$99,000

$8,250

$5,500.00

$248.05

$198.00 $163.35 $111.65

$96.80

$74.80

Plan B Accident/Sickness Benefit Waiting Period Monthly Cost

Burleson ISD

38

14 /14

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

90/90

180/180

$3,600

$300

$200.00

$8.04

$6.36

$5.32

$3.62

$3.14

$2.42

$5,400

$450

$300.00

$12.06

$9.54

$7.98

$5.43

$4.71

$3.63

$7,200

$600

$400.00

$16.08

$12.72

$10.64

$7.24

$6.28

$4.84

$9,000

$750

$500.00

$20.10

$15.90

$13.30

$9.05

$7.85

$6.05

$10,800

$900

$600.00

$24.12

$19.08

$15.96

$10.86

$9.42

$7.26

$12,600

$1,050

$700.00

$28.14

$22.26

$18.62

$12.67

$10.99

$8.47

$14,400

$1,200

$800.00

$32.16

$25.44

$21.28

$14.48

$12.56

$9.68

$16,200

$1,350

$900.00

$36.18

$28.62

$23.94

$16.29

$14.13

$10.89

$18,000

$1,500

$1,000.00

$40.20

$31.80

$26.60

$18.10

$15.70

$12.10

$19,800

$1,650

$1,100.00

$44.22

$34.98

$29.26

$19.91

$17.27

$13.31

$21,600

$1,800

$1,200.00

$48.24

$38.16

$31.92

$21.72

$18.84

$14.52

$23,400

$1,950

$1,300.00

$52.26

$41.34

$34.58

$23.53

$20.41

$15.73

$25,200

$2,100

$1,400.00

$56.28

$44.52

$37.24

$25.34

$21.98

$16.94

$27,000

$2,250

$1,500.00

$60.30

$47.70

$39.90

$27.15

$23.55

$18.15

$28,800

$2,400

$1,600.00

$64.32

$50.88

$42.56

$28.96

$25.12

$19.36

$30,600

$2,550

$1,700.00

$68.34

$54.06

$45.22

$30.77

$26.69

$20.57


Long Term Disability Plan B Accident/Sickness Benefit Waiting Period Monthly Cost

Burleson ISD Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

90/90

180/180

$32,400

$2,700

$1,800.00

$72.36

$57.24

$47.88

$32.58

$28.26

$21.78

$34,200

$2,850

$1,900.00

$76.38

$60.42

$50.54

$34.39

$29.83

$22.99

$36,000

$3,000

$2,000.00

$80.40

$63.60

$53.20

$36.20

$31.40

$24.20

$37,800

$3,150

$2,100.00

$84.42

$66.78

$55.86

$38.01

$32.97

$25.41

$39,600

$3,300

$2,200.00

$88.44

$69.96

$58.52

$39.82

$34.54

$26.62

$41,400

$3,450

$2,300.00

$92.46

$73.14

$61.18

$41.63

$36.11

$27.83

$43,200

$3,600

$2,400.00

$96.48

$76.32

$63.84

$43.44

$37.68

$29.04

$45,000

$3,750

$2,500.00

$100.50

$79.50

$66.50

$45.25

$39.25

$30.25

$46,800

$3,900

$2,600.00

$104.52

$82.68

$69.16

$47.06

$40.82

$31.46

$48,600

$4,050

$2,700.00

$108.54

$85.86

$71.82

$48.87

$42.39

$32.67

$50,400

$4,200

$2,800.00

$112.56

$89.04

$74.48

$50.68

$43.96

$33.88

$52,200

$4,350

$2,900.00

$116.58

$92.22

$77.14

$52.49

$45.53

$35.09

$54,000

$4,500

$3,000.00

$120.60

$95.40

$79.80

$54.30

$47.10

$36.30

$55,800

$4,650

$3,100.00

$124.62

$98.58

$82.46

$56.11

$48.67

$37.51

$57,600

$4,800

$3,200.00

$128.64

$101.76

$85.12

$57.92

$50.24

$38.72

$59,400

$4,950

$3,300.00

$132.66

$104.94

$87.78

$59.73

$51.81

$39.93

$61,200

$5,100

$3,400.00

$136.68

$108.12

$90.44

$61.54

$53.38

$41.14

$63,000

$5,250

$3,500.00

$140.70

$111.30

$93.10

$63.35

$54.95

$42.35

$64,800

$5,400

$3,600.00

$144.72

$114.48

$95.76

$65.16

$56.52

$43.56

$66,600

$5,550

$3,700.00

$148.74

$117.66

$98.42

$66.97

$58.09

$44.77

$68,400

$5,700

$3,800.00

$152.76

$120.84 $101.08

$68.78

$59.66

$45.98

$70,200

$5,850

$3,900.00

$156.78

$124.02 $103.74

$70.59

$61.23

$47.19

$72,000

$6,000

$4,000.00

$160.80

$127.20 $106.40

$72.40

$62.80

$48.40

$73,800

$6,150

$4,100.00

$164.82

$130.38 $109.06

$74.21

$64.37

$49.61

$75,600

$6,300

$4,200.00

$168.84

$133.56 $111.72

$76.02

$65.94

$50.82

$77,400

$6,450

$4,300.00

$172.86

$136.74 $114.38

$77.83

$67.51

$52.03

$79,200

$6,600

$4,400.00

$176.88

$139.92 $117.04

$79.64

$69.08

$53.24

$81,000

$6,750

$4,500.00

$180.90

$143.10 $119.70

$81.45

$70.65

$54.45

$82,800

$6,900

$4,600.00

$184.92

$146.28 $122.36

$83.26

$72.22

$55.66

$84,600

$7,050

$4,700.00

$188.94

$149.46 $125.02

$85.07

$73.79

$56.87

$86,400

$7,200

$4,800.00

$192.96

$152.64 $127.68

$86.88

$75.36

$58.08

$88,200

$7,350

$4,900.00

$196.98

$155.82 $130.34

$88.69

$76.93

$59.29

$90,000

$7,500

$5,000.00

$201.00

$159.00 $133.00

$90.50

$78.50

$60.50

$91,800

$7,650

$5,100.00

$205.02

$162.18 $135.66

$92.31

$80.07

$61.71

$93,600

$7,800

$5,200.00

$209.04

$165.36 $138.32

$94.12

$81.64

$62.92

$95,400

$7,950

$5,300.00

$213.06

$168.54 $140.98

$95.93

$83.21

$64.13

$97,200

$8,100

$5,400.00

$217.08

$171.72 $143.64

$97.74

$84.78

$65.34

$99,000

$8,250

$5,500.00

$221.10

$174.90 $146.30

$99.55

$86.35

$66.55 39


AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS

About this Benefit Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.

DID YOU KNOW? Breast Cancer is the most commonly diagnosed cancer in women.

If caught early, prostate cancer is one of the most treatable malignancies.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd (03/16)

40


GC3 Limited Benefit Group Cancer Indemnity Insurance Burleson ISD THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits* Benefits

Level 1 Base Plan

Level 2 Base Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$500 per calendar month of treatment

$1,500 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

$1,600 max per operation; $15 per surgical unit

$4,800 max per operation; $45 per surgical unit

Anesthesia Benefit

25% of the amount paid for covered surgery

25% of the amount paid for covered surgery

Hospital Confinement Benefit

$100 per day 1-90 days; $100 per day, 91+ days in lieu of other benefits

$300 per day 1-90 days; $300 per day, 91+ days in lieu of other benefits

US Government/Charity Hospital/HMO

$100 per day in lieu of most other benefits

$300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery

$600 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

$150 per confinement

Drugs & Medicine Benefit - Outpatient

$50 per prescription, up to $50 per cal month

$50 per prescription, up to $150 per cal month

Transportation & Outpatient Lodging Benefit

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

Family Member Transportation & Lodging Benefit

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

Blood, Plasma & Platelets Benefit

$150 per day, up to $7,500 per calendar year

$250 per day, up to $12,500 per calendar year

Bone Marrow/Stem Cell Transplant

Autologous - $500 per calendar year Non-Autologous - $1,500 per calendar year

Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year

Experimental Treatment Benefit

Pays as any non-experimental benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$30 per day of confinement

$50 per day of confinement

Surgical Prosthesis Benefit

$1,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

$3,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

$100 per day, 1-90 days of hospital confinement

$300 per day, 1-90 days of hospital confinement

Hospice Care Benefit

$50 per day, $9,000 lifetime max

$100 per day, $18,000 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

$200 per ground trip

Ambulance Air Benefit

$2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air)

$2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air)

Extended Care Benefit

$100 per day

$300 per day

Home Health Care Benefit

$100 per day

$300 per day

Second & Third Surgical Opinions

$300 per diagnosis; additional $300 if third opinion required

$300 per diagnosis; additional $300 if third opinion required

Waiver of Premium

Premium waived after 90 days of primary insured continuous total disability due to cancer

Premium waived after 90 days of primary insured continuous total disability due to cancer

Physical/Speech Therapy Benefit

$25 per visit, up to 4 visits per calendar month, $1,000 lifetime max

$25 per visit, up to 4 visits per calendar month, $1,000 lifetime max

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

$50; 1 person, per calendar year

Critical Illness Rider: Cancer

$2,500 lump sum benefit

$2,500 lump sum benefit

Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Riders

Optional Benefit Rider Intensive Care Unit Rider Monthly Premium**

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$14.50

$17.80

$30.60

$33.90

One Parent

$20.30

$24.80

$42.10

$46.60

$25.90

$32.80

$53.50

$60.40

Two Parent

*Premium and amount of benefits provided vary dependent upon the level selected at time of application. **Total premium includes the policy and riders of the option selected.

APSB-22356(TX) MGM/FBS Burleson ISD-0315

41


GC3 Limited Benefit Group Cancer Indemnity Insurance Eligibility

This policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage. If You are working either under contract to or as a Full-Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us.

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer. No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

Diagnostic Testing Benefit Rider

We will pay the indemnity amount for one generally medically recognized internal cancer screening test per covered person per calendar year. Screening test include, but limited to: mammogram; breast ultrasound; breast thermography; breast cancer blood test (CA15-3); colon cancer blood test (CEA); prostate-specific antigen blood test (PSA); flexible sigmoidoscopy; colonoscopy; virtual colonoscopy; ovarian cancer blood test (CA-125); pap smear (lab test required); chest x-ray; hemocult stool specimen; serum protein electrophoresis (blood test for myeloma); thin prep pap test. Screening tests payable under this benefit will only be paid under this benefit. Benefits will only be paid for tests performed after the 30-day period following the covered person’s effective date of coverage. 42MGM/FBS Burleson ISD APSB-22356(TX)

Critical Illness Rider

Benefits will only be paid for a covered critical illness as shown on the policy/ certificate schedule page in the policy. No benefits will be provided for any loss caused by or resulting from: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; or alcoholism or drug addiction; or any act of war, declared or undeclared , or any act related to war; or military service for any country at war; or a pre-existing condition; or a covered critical illness when the date of diagnosis occurs during the waiting period; or participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in a felony, riot or insurrection (a felony is as defined by the law of the jurisdiction in which the activity takes place). Internal cancer does not include: other conditions that may be considered pre-cancerous or having malignant potential such as: acquired immune deficiency syndrome (AIDS); or actinic keratosis; or myelodysplastic and non-malignant myeloproliferative disorders; or aplastic anemia; or atypia; or non-malignant monoclonal gamopathy; or Leukoplakia; or Hyperplasia; or Carcinold; or Polycythemia; or carcinoma in situ or any skin cancer other than invasive malignant melanoma into the dermis or deeper. For a pre-existing condition no benefits are payable. Pre-Existing Condition, as used in this rider means any sickness or condition for which prior to the Effective Date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment.

Hospital Intensive Care Unit Rider

No benefits will be provided during the first two years of this rider for hospital intensive care unit confinement caused by any heart condition when any heart condition was diagnosed or treated prior to the 30th day following the covered person’s effective date of this rider. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. No benefits will be provided if the loss results from: attempted suicide, whether sane or insane; or intentional self-injury; or alcoholism or drug addiction; or any act of war, declared or undeclared, or any act related to war; or military service for a country at war. No benefits will be paid for confinements in units such as surgical recovery rooms, progressive care, burn units, intermediate care, private monitored rooms, observation units, telemetry units or psychiatric units not involving intensive medical care; or other facilities which do not meet the standards for intensive care unit as defined in the rider. For a newborn child born within the tenmonth period following the effective date of this rider, no benefits will be provided for hospital intensive care unit confinement that begins within the first 30 days following the birth of such child.


GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

This policy/certificate is conditionally renewable. This means that We have the right to terminate your policy/certificate on any premium due date after the first Policyholder’s Anniversary Date. We must give the Policyholder at least 60 days written notice prior to cancellation. We cannot cancel Your coverage because of a change in Your age or health. We can change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums.

Continuation Rider Continuation

Coverage is continued when the Insured (You) cease employment with the employer through whom You originally became insured under the Policy. You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our home office. Premiums must be paid within thirty-one (31) days after employment with your employer terminates. Premium rates required under this Continuation provision will be the same rates as those charged under the Employer’s Policy as if You had continued employment. We will bill You for these premiums after You notify Us to continue this coverage. Coverage will continue until the earlier of: (1) the Policy under which You originally became insured ends; or (2) You stop paying premiums under this option (subject to the terms of the Grace Period).

Termination of Coverage

Your Insurance coverage will end on the earliest of these dates: (a) the date You no longer qualify as an Insured; (b) the last day of the period for which a premium has been paid, subject to the Grace Period; (c) the date the Policy terminates (See Conversion provision); (d) the date You retire; (e) the date You cease employment, or terminate Your contract with the employer through whom You originally became insured under the Policy (See Conversion provision); or (f) the date We receive Your written request for termination. Termination of Dependent(s) Insurance coverage on Your Dependent(s) will end on the earliest of these dates: (a) the date the coverage under the Certificate terminates; (b) the date the Dependent no longer meets the definition of Dependent, as defined in the Policy/Certificate (See Conversion provision); (c) the date We receive Your written request for termination.  

Termination of Rider Coverage

This rider terminates: (a) when Your coverage terminates under the Policy/ Certificate to which this Rider is attached; or, (b) when any premium for this rider is not paid before the end of the Grace Period; or, (c) when You give Us a written request to do so. Coverage on a Dependent terminates under this rider when such person ceases to meet the definition of Dependent, as defined in the Policy.

Conversion

If the Employer’s Policy is terminated, this Certificate will terminate. Upon termination of the Employer’s Policy, the employee (You) will be entitled to convert to an individual policy of insurance issued by Us without evidence of insurability provided the required premiums have been paid on your behalf and You notified Us in writing within thirty-one (31) days of the Employer’s Policy termination. Premiums for the individual policy of insurance will be figured from the premium rate table in effect on the date of conversion. Subject to the terms of this provision, a covered child who ceases to be eligible may convert to an individual policy of insurance and a covered spouse who ceases to be eligible for coverage because of divorce or annulment may convert to an individual policy. Terms of this provision include: (1) Application for the individual policy and payment of the first premium must be made within 60 days after coverage ceases under the Policy/Certificate. Premiums will be figured from the premium rate table in effect on the date of conversion. (2) The individual policy will be issued without proof of insurability. It will provide benefits that most nearly approximates those of the Policy/Certificate. (3) The individual policy will take effect the day after coverage ceases under the Policy/Certificate. However, no benefits will be payable under the individual policy for any loss for which benefits are payable under the Policy/Certificate. (4) The Pre-Existing Condition Limitation and Time Limit on Certain Defenses provisions for the individual policy will be figured from the Covered Person’s Effective Date of coverage under the Policy/ Certificate. (5) Any benefit maximums will be figured from the Effective Date of the Policy/Certificate. This rider is subject to all the provisions of the Policy and Certificate to which it is attached that are not in conflict with this rider.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/ riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC-3 Series | Texas | Limited Benefit Group Cancer Indemnity Insurance Policy | (11/14) | Burleson ISD

APSB-22356(TX) MGM/FBS Burleson ISD-0315

43


UNUM YOUR BENEFITS PACKAGE

Life and AD&D

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

DID YOU KNOW? Motor vehicle crashes are the

#1

cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 44


Life and AD&D Eligibility All employees working at least 30 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 26.

Basic Coverage Amounts Employee: $10,000 Term Life and AD&D

Voluntary Coverage Amounts Your Term Life and AD&D coverage options are: Employee: Up to 7 times salary in increments of $10,000. Not to exceed $500,000. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee. Child: Up to 100% of employee coverage amount in increments of $10,000. Not to exceed $10,000. Benefits will be paid to the employee. In order to purchase Life coverage for your spouse and/or child, you must purchase Life coverage for yourself. In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself. AD&D Benefit Schedule: The full benefit amount is paid for loss of:  Life  Both hands or both feet or sight of both eyes  One hand and one foot  One hand and the sight of one eye  One foot and the sight of one eye  Speech and hearing Other losses may be covered as well. Please see your Plan Administrator. Coverage amount(s) will reduce according to the following schedule: Age: Insurance Amount Reduces to: 70 65% of original amount 75 45% of original amount 80 30% of original amount 85 20% of original amount 90 15% of original amount

enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your Life insurance coverage, with evidence of insurability, at anytime during the year. However, you may wait until the next annual enrollment and only Life insurance coverage over the Guarantee Issue amounts will be subject to evidence of insurability. Please see your Plan Administrator for your eligibility date.

Additional Benefits Life Planning Financial & Legal Resources This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. The financial consultants are master level consultants. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security. At no time will the consultants offer or sell any product or service.

Portability/Conversion If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy.

Accelerated Benefit If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 50% of your life insurance amount up to $750,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies). This feature also applies to your covered dependents.

Waiver of Premium If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability.

Coverage may not be increased after a reduction.

Retained Asset Account Guarantee Issue If you and your eligible dependents enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance coverage up to $200,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amounts will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual

Benefits of $10,000 or more are paid through the Unum Retained Asset Account. This interest bearing account will be established in the beneficiary's name. He or she can then write a check for the full amount or for $250 or more, as needed.

Additional AD&D Benefits Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent

45


Life and AD&D child(ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.)

Unum will provide coverage for a payable claim which occurs while you and your dependents are covered under the policy or plan.

Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.

Next Steps How to Apply

Limitations/Exclusions/Termination of Coverage Suicide Exclusion

New Hires: To apply for coverage, complete your enrollment form within 31 days of your eligibility date.

Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage. No increased or additional benefits will be payable for deaths caused by suicide occurring within 24 months after the day such increased or additional insurance is effective.

AD&D Benefit Exclusions AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from:  Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders;  Suicide, self-destruction while sane, intentionally self-inflicted injury while sane, or self-inflicted injury while insane;  War, declared or undeclared, or any act of war;  Active participation in a riot;  Attempt to commit or commission of a crime;  The voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol;  Intoxication. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.)

Termination of Coverage Your coverage and your dependents’ coverage under the Summary of Benefits ends on the earliest of:  The date the policy or plan is cancelled;  The date you no longer are in an eligible group;  The date your eligible group is no longer covered;  The last day of the period for which you made any required contributions;  The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage;  For dependent’s coverage, the date of your death. In addition, coverage for any one dependent will end on the earliest of:  The date your coverage under a plan ends;  The date your dependent ceases to be an eligible dependent;  For a spouse, the date of divorce or annulment.

46

Current Employees: To apply for coverage, complete your enrollment form by the enrollment deadline

All Employees: If you apply for coverage after your effective date, or if you choose coverage over the guarantee issue amount, you will need to complete a medical questionnaire which you can get from your Plan Administrator. You may also be required to take certain medical tests at Unum’s expense.

Effective Date of Coverage Please see your Plan Administrator for your effective date.

Delayed Effective Date of Coverage Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth. “Totally disabled” means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life threatening condition.

Changes to Coverage Each year you and your spouse will be given the opportunity to change your Life coverage and AD&D coverage. You and your spouse may purchase additional Life coverage up to one benefit unit increase without evidence of insurability if you are already enrolled in the plan. Elected Life coverage over the one benefit unit increase will be medically underwritten and will require evidence of insurability and approval by Unum’s Medical Underwriters. The suicide exclusion will apply to any increase in coverage. AD&D coverage does not require evidence of insurability for increase amounts.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.


Life and AD&D Term Life Coverage Rates EMPLOYEE*

$10,000

$20,000

$30,000

$40,000

$50,000

$70,000

$100,000

$130,000

$150,000

0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

$0.42 $0.42 $0.48 $0.57 $0.89 $1.51 $2.51 $3.91 $6.12

$0.84 $0.84 $0.96 $1.14 $1.78 $3.02 $5.02 $7.82 $12.24

$1.26 $1.26 $1.44 $1.71 $2.67 $4.53 $7.53 $11.73 $18.36

$1.68 $1.68 $1.92 $2.28 $3.56 $6.04 $10.04 $15.64 $24.48

$2.10 $2.10 $2.40 $2.85 $4.45 $7.55 $12.55 $19.55 $30.60

$2.94 $2.94 $3.36 $3.99 $6.23 $10.57 $17.57 $27.37 $42.84

$4.20 $4.20 $4.80 $5.70 $8.90 $15.10 $25.10 $39.10 $61.20

$5.46 $5.46 $6.24 $7.41 $11.57 $19.63 $32.63 $50.83 $79.56

$6.30 $6.30 $7.20 $8.55 $13.35 $22.65 $37.65 $58.65 $91.80

65-69 70-74 75+

$10.97 $19.65 $32.40

$21.94 $39.30 $64.80

$32.91 $58.95 $97.20

$43.88 $78.60 $129.60

$54.85 $98.25 $162.00

$76.79 $137.55 $226.80

$109.70 $196.50 $324.00

$142.61 $255.45 $421.20

$164.55 $294.75 $486.00

Age Band

EMPLOYEE ACCIDENTAL DEATH & DISMEMBERMENT RATES: 0-79+

$0.25

$0.50

$0.75

$1.00

$1.25

$1.75

$2.50

$3.25

$3.75

SPOUSE**

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$50,000

Age Band 0-24

$0.21

$0.42

$0.63

$0.84

$1.05

$1.26

$1.47

$1.68

$2.10

25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74

$0.21 $0.24 $0.29 $0.45 $0.76 $1.25 $1.96 $3.06 $5.49 $5.49

$0.42 $0.48 $0.57 $0.89 $1.51 $2.50 $3.91 $6.12 $10.97 $10.97

$0.63 $0.72 $0.86 $1.34 $2.27 $3.75 $5.87 $9.18 $16.46 $16.46

$0.84 $0.96 $1.14 $1.78 $3.02 $5.00 $7.82 $12.24 $21.94 $21.94

$1.05 $1.20 $1.43 $2.23 $3.78 $6.25 $9.78 $15.30 $27.43 $27.43

$1.26 $1.44 $1.71 $2.67 $4.53 $7.50 $11.73 $18.36 $32.91 $32.91

$1.47 $1.68 $2.00 $3.12 $5.29 $8.75 $13.69 $21.42 $38.40 $38.40

$1.68 $1.92 $2.28 $3.56 $6.04 $10.00 $15.64 $24.48 $43.88 $43.88

$2.10 $2.40 $2.85 $4.45 $7.55 $12.50 $19.55 $30.60 $54.85 $54.85

75+

$5.49

$10.97

$16.46

$21.94

$27.43

$32.91

$38.40

$43.88

$54.85

$0.50

$0.63

$0.75

$0.88

$1.00

$1.25

SPOUSE ACCIDENTAL DEATH & DISMEMBERMENT RATES: 0-79+

$0.13

$0.25

$0.38

CHILD(REN) LIFE AD&D

$10,000 $0.78 $0.25

*$200,000 is the maximum that may be issued without answering health questions. **$50,000 is the maximum that may be issued without answering health questions. NOTE: Final rates may vary slightly due to rounding.

47


ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

DID YOU KNOW?

An identity is stolen every

2 seconds, and takes over

300 hours to resolve, causing an average loss of $9,650.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 48


Identity Theft ADVANCED TOOLS

DUAL MONTHLY PRICING Plus

Platinum

Breach Notification

Individual

$7.95

$11.95

Solicitation Reduction

Family

$14.95

$22.95

CREDIT PROTECTION SERVICES

  

Tri-bureau monitoring and TransUnion® report and score.

Monthly Credit Score Tracker Historical view of TransUnion scores.

Credit Freeze Fraud Alert Assistance & Reminders

Assistance with setting credit bureau fraud alerts and reminders.

PROACTIVE IDENTITY MONITORING 

Public Records & NCOA Monitoring We monitor the National Change of Address Registry and public records databases (over 37 billion consumer records). Direct network access enables us to detect potential fraud faster.

Payday Loan Monitoring We work directly with alternative credit bureaus that service the under-banked market. Our network monitors the largest database so we can alert faster.

Enhanced Non-Credit Loan Monitoring

Our expanded fraud detection network includes monitoring of  auto pawn, rent-to-own, sub-prime, and cell phone accounts. Protection is increased by scanning for these common transactions that require minimal information to obtain.

High-Risk Application & Transaction Monitoring Real-time alerts cover new account applications such as financial and wireless. Real-time alerts inform you of critical transactions including bank password resets, online healthcare, payroll account, or insurance records access. We catch potential identity theft up to 90 days sooner.

Cyber Monitoring

Instant-On promptly activates all monitoring on the benefit effective date without any further action required by the employee.

2-Step Authentication

Identity Profile Report Our report helps surface any pre-existing conditions going back 30 years or more.

Social Network Alerts Add alert customizations to Facebook, LinkedIn, Instagram, and Twitter accounts to stay on top of potential cyberbullying, cyber predators, and reputation-damaging items directed at you and your family. Our exclusive identity exposure report highlights PHI published on social sites and calls out increased potential for identity theft.

Registered Sex Offender Reporting & Alerts Run a report for a specific address showing location, photo ID, and the offense committed. Search for sex offenders in your area and receive alerts when new offenders move into your neighborhood. We track and report offenders who move from state to state who can be missed in an online state search. Real-time reporting is available for all ID Watchdog plans. Collect maximum information from one source to keep loved ones safe.

National Provider Identifier (NPI) Alerts We monitor the NPI database for activity that indicates potential fraud. We are the only vendor who monitors this database and provides alerts to physicians, pharmacists, and more if their credentials are compromised.

Password Manager Securely store and use login information and access it with a single master password. COMING IN 2016

ADVANCED CUSTOMER CARE CENTER 

Underground websites are scanned daily in search of personal information being sold. When detected in our scans, we send a compromised credentials alert.

Instant-On™ Monitoring

Lost Wallet Vault & Replacement

To ensure your information is accurate and secure, we require a 2-step authentication process when logging in to and registering your account.

Rapid Credit Alerts Credit alerts provided within minutes of detected activity change.

Opt in or out of the National Do Not Call Registry, preapproved credit offers, junk mail, or email. Store your wallet contents in our secure digital vault. Lost Wallet Replacement will assist with cancelling and replacing contents from the Lost Wallet Vault.

Credit Monitoring, Report & Score(s)

Assistance with putting a security freeze on your credit report. Credentials are securely stored for easy access.

Receive email notification of prominent data breaches.

  

Fully Managed Resolution Service Dedicated CITRMS work with you to assess your identity theft situation and will manage your case until it is completely restored.

$1M Expense Reimbursement Insurance The plan covers financial damages incurred as a result of the theft.

Call Center Commitment to Excellence Real-time language support ensures clear communication with over 100 languages.

24/7 Call Center Reach an identity theft protection specialist when you need help.

49


NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless used during the 75 day grace period.

Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.

FLIP TO‌ PG. 11 FOR HSA VS. FSA COMPARISON This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Burleson ISD Benefits Website: www.mybenefitshub.com/burlesonisd 50


FSA (Flexible Spending Account) NBS Flexcard You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card.

NBS Prepaid MasterCard® Debit Card

When Will I Receive My Flex Card? New participants can expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years! For a list of sample expenses, please refer to the Burleson ISD benefit website: www.mybenefitshub.com/burlesonisd

NBS Contact Information: You must file web or paper claims or enroll in continual reimbursement.

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you need a replacement card please contact NBS directly at (800) 274-0503.

New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.

8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: service@nbsbenefits.com

DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses.

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com    

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs 51


FSA Frequently Asked Questions What is a Flexible Spending Account? A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.

Health Care Expense Account Example Expenses:          

Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid

        

Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers

Dependent Care Expense Account Example Expenses:    

Before and After School and/or Extended Day Programs The actual care of the dependent in your home. Preschool tuition. The base costs for day camps or similar programs used as care for a qualifying individual.

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenefitshub.com/burlesonisd

52

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/ burlesonisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

How To Receive Your Dependent Care Reimbursement Faster. A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!


How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1. 2. 3. 4.

Complete and sign a claim form (available on our website) or an online claim. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes:  Detailed claim history and processing status  Health Care and Dependent Care account balances  Claim forms, worksheets, etc.  Online Claim Submission

Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period or rollover after the Plan year ends for you to submit qualified claims for any unused funds.

53


NOTES

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NOTES

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www.mybenefitshub.com/burlesonisd

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2016 Benefit Guide Burleson ISD  
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