2016 Benefit Guide - City of Mount Pleasant

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CITY OF MOUNT PLEASANT

BENEFIT GUIDE EFFECTIVE: 10/01/2016 - 09/30/2017 www.mybenefitshub.com/cityofmtpleasant

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Table of Contents FLIP TO... Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Annual Enrollment 2. Eligibility Requirements 3. Helpful Definitions 4. Section 125 Cafeteria Plan Guidelines Blue Cross Blue Shield of Texas Medical Cigna Dental Superior Vision Lincoln Financial Short Term Disability APL Cancer AUL a OneAmerica Company Life and AD&D Ceridian Employee Assistance Program (EAP) 5Star Individual Life NBS Flexible Spending Account (FSA)

3 4-5 6-9 6 7 8 9 10-15 16-19 20-21 22-23 24-27 28-31 32-33 34-37 38-41

PG. 4 HOW TO ENROLL

PG. 6 YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 10 YOUR BENEFITS PACKAGE

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Benefit Contact Information

Benefit Contact Information BENEFIT ADMINISTRATORS

VISION

EMPLOYEE ASSISTANCE PROGRAM

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

Policy # 326600 Superior Vision (Superior Select Southwest Network) (800) 507-3800 www.superiorvision.com

AUL a OneAmerica Company (800) 537-6442 www.oneamerica.com

CITY OF MT PLEASANT BENEFITS

SHORT TERM DISABILITY

INDIVIDUAL LIFE

Darleen Denman (903) 575-4000 ddenman@mpcity.org

Policy # 395317 Lincoln Financial Group (800) 423-2765 www.lincolnfinancial.com

5Star Life Insurance (800) 776-2322 www.5starima.com

MEDICAL

CANCER

FLEXIBLE SPENDING ACCOUNT

Group # RM45 Blue Cross Blue Shield of Texas (800) 521-2227 www.bcbstx.com

Policy # 14702 American Public Life (800) 256-8608 www.ampublic.com

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

DENTAL

BASIC & VOLUNTARY LIFE

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

Group # GFZ0395 AUL a OneAmerica Company (800) 537-6442 www.oneamerica.com

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

TEXT

need to complete your enrollment.

“cityofmp” 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 City of Mount Pleasant

Our online benefit enrollment

benefits website from your

platform provides a simple and

computer, tablet or smartphone!

easy to navigate process. Enroll at your own pace, whether at home or at work. www.mybenefitshub.com/ cityofmtpleasant 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/cityofmtpleasant

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

Annual Enrollment

Q&A

During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs.

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.

Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.

 Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.

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.

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.

Where can I find forms? For benefit summaries and claim forms, go to the City of Mount Pleasant benefit website: www.mybenefitshub.com/ cityofmtpleasant. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section. How can I find a Network Provider? For benefit summaries and claim forms, go to the City of Mount Pleasant benefit website: www.mybenefitshub.com/ cityofmtpleasant. Click on the benefit plan you need information on (i.e., Dental) and you can find 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 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.

Don’t Forget!   

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Login and complete your benefit enrollment. Update your profile information: home address, phone numbers, email. Enrollment assistance is available by calling Financial Benefit Services at (469) 385-4640 to speak to a representative. Update beneficiary and dependent social security numbers and student status for college aged children.


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.

date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2016 benefits become effective on October 1, 2016, you must be actively-at-work on October 1, 2016 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

Blue Cross Blue Shield of Texas

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Dental

Cigna

26

Vision

Superior Vision

25

Voluntary & Basic Life

AUL a OneAmerica Company

26

Cancer

APL

25

Disability

Lincoln Financial Group

26

Individual Life

5 Star Life Insurance Company

18-24 (full time college student)

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 10/1/2016 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 October 1st through September 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

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 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.

CHANGES IN STATUS (CIS):

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 Government Programs

Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

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BLUE CROSS BLUE SHIELD OF TEXAS

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.

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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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


Medical Blue Choice PPO MM45 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 10/01/2016—09/30/2017 Coverage for: All | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbstx.com/member/policy-forms/ or by calling 1-800-521-2227. Questions

Answers

Why this Matters:

What is the overall deductible?

For Network: $3,000 Individual/$9,000 Family For Out-of-Network: $6,000 Individual/$18,000 Family Doesn't apply to In-Network preventive care, InNetwork office visits, or prescription drugs. Copays and prescription drug costs don't count toward the overall deductible.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. For Network: $5,600 Individual/$10,200 Family For Out-of-Network: $16,000 Individual/$48,000 Family Rx Out-of-Pocket expense limit: $1,000 Individual/$3,000 Family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

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

Premiums, balance-billed charges, and health care this plan doesn't cover.

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

Does this plan use a network of providers?

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

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don't need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn't cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Questions: Call 1-800-521-2227 or visit us at www.bcbstx.com/coverage If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy. 11


Medical    

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) The plan may encourage you to use Network providers by charging you lower deductibles, copayments, and coinsurance amounts.

Common Medical Event

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

If you have a test

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

If you have outpatient surgery

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Services You May Need

Your cost if Your cost if you use an you use a Out-of-Network Network Provider Provider

Primary care visit to treat an injury or illness

$45 copay/visit

30% coinsurance

Specialist visit

$45 copay/visit

30% coinsurance

Other practitioner office visit

$45 copay/visit

30% coinsurance

Preventive care/ screening/ immunization

No Charge

30% coinsurance

Diagnostic test (x-ray, blood work)

No Charge

30% coinsurance

Limitations & Exceptions

None

There is No Charge for Out-ofNetwork immunizations from birth through the day of the 6th birthday.

None

Imaging (CT/PET scans, MRIs)

30% coinsurance

50% coinsurance

Generic drugs

$20 copay/ prescription

20% coinsurance plus copay

Preferred brand drugs

$40 copay/ prescription

20% coinsurance plus copay

Non-preferred brand drugs

$60 copay/ prescription

20% coinsurance plus copay

Specialty drugs

$20/$40/$60 copay/prescription

20% coinsurance plus copay

Facility fee (e.g., ambulatory surgery center)

30% coinsurance

50% coinsurance

Physician/ surgeon fees

30% coinsurance

One copay per 30-day supply - up to a 90-day supply for generic and brand drugs, up to a 30-day supply for specialty drugs. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Certain women's preventive services will be covered with no cost to the member. Rx Outof-Pocket expense limit: $1,000 Individual/$3,000 Family.

None 50% coinsurance


Medical

Common Medical Event

If you need immediate medical attention

Services You May Need

Your cost if you use a Network Provider

Your cost if you use an Out-of-Network Provider

Limitations & Exceptions

Emergency room services

30% coinsurance after $100 copay/visit

30% coinsurance after $100 copay/visit

Copay amount waived if admitted.

Emergency medical transportation

30% coinsurance

30% coinsurance None

Urgent care

$70 copay/visit

30% coinsurance

Facility fee (e.g., hospital room)

30% coinsurance

50% coinsurance

Preauthorization required Outof-Network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Physician/ surgeon fee

30% coinsurance

50% coinsurance

None

Mental/behavioral health outpatient services

$45 copay for office visits or 30% coinsurance for other outpatient services

50% coinsurance

Mental/behavioral health inpatient services

30% coinsurance

50% coinsurance

Substance use disorder outpatient services

$45 copay for office visits or 30% coinsurance for other outpatient services

50% coinsurance

Substance use disorder inpatient services

30% coinsurance

50% coinsurance

Prenatal and postnatal care

$45 copay/visit

30% coinsurance

Delivery and all inpatient services

30% coinsurance

50% coinsurance

If you have a hospital stay

If you have mental health, behavioral health, or substance abuse needs

Outpatient: Preauthorization required for psychological testing, neuropsychological testing, electroconvulsive therapy, repetitive transcranial magnetic stimulation, and intensive outpatient treatment; failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500). Inpatient: Preauthorization required Outof-Network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Copay applies to first prenatal visit (per pregnancy).

If you are pregnant

None

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Medical

Common Medical Event

If you need help recovering or have other special health needs

If your child needs dental or eye care

Services You May Need

Your cost if you use a Network Provider

Your cost if you use an Out-of-Network Provider

Limitations & Exceptions

60 visit maximum per benefit period. Preauthorization required Out-of Network; failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500).

Home health care

No Charge

30% coinsurance

Rehabilitation services

30% coinsurance

50% coinsurance

Habilitation services

30% coinsurance

50% coinsurance

Limited to combined 35 visits per year, including Chiropractic. 25 day maximum per benefit period. Preauthorization required Out-ofNetwork; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Skilled nursing care

No Charge

30% coinsurance

Durable medical equipment

30% coinsurance

50% coinsurance

None

Preauthorization required Out-ofNetwork; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

Hospice service

No Charge

30% coinsurance

Eye exam Glasses

Covered Not Covered

Not Covered Not Covered

Dental check-up

Not Covered

Not Covered

None

Excluded Services & Other Covered Services Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)  Abortions  Acupuncture  Bariatric surgery  Cosmetic surgery  Dental care (Adult)  Long term care  Private duty nursing  Weight loss programs

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Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)  Chiropractic care  Hearing aids  Infertility treatment (Invitro and artificial insemination are not covered unless shown in your plan document)  Non-emergency care when traveling outside the U.S.  Routine eye care (Adult)  Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)


Medical Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-521-2227. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com or contact U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/ healthreform.

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Questions Call 1-800-521-2227 or visit us at www.bcbstx.com/coverage. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.

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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.

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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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


Dental PPO Benefits

Network

Cigna Dental PPO

Monthly PPO Premiums

In-Network

Out-of-Network

Cigna Choice-Radius

Cigna Savings-Radius

$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

Calendar Year Maximum (Class I, II, and III expenses) Annual Deductible Individual Family Reimbursement Levels**

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%

Tier

Rate

EE Only

$29.13

Family Coverage

$97.04

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Full Mouth X-rays Bitewing X-rays Panoramic X-ray Periapical X-rays Fluoride Application Sealants Space Maintainers Emergency Care to Relieve Pain Histopathologic Exams

Class II - Basic Restorative Care Fillings Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Denture Adjustments and Repairs Oral Surgery – Simple Extractions Oral Surgery – all except simple extractions Anesthetics Surgical Extractions of Impacted Teeth Repairs to Bridges, Crowns and Inlays

Class III - Major Restorative Care Crowns Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia Lifetime Maximum

50% $1,000 Dependent children to age 19

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 12 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.

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Dental PPO Benefit Exclusions                    

    

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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.


Dental PPO 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 12 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 and extensive Perio treatment 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

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: HPPOL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: 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. BSD39531 © 2015 Cigna

19


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.

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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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


Vision Benefits Exam Frames Contact Lenses1

In-Network

Out-of-Network

Covered in full $125 retail allowance $150 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

Monthly Premiums EE only EE + 1 Dependent EE + Family

$7.87 $13.40 $19.71

Co-Pays Exam Materials

$10 $25

Services/Frequency 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

Exam Frame Lenses Contact Lenses

12 months 12 months 12 months 12 months

(Based on date of service)

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 1

Contact lenses and related professional services (fitting, evaluation and follow-up) 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 21


LINCOLN FINANCIAL

Short Term Disability

YOUR BENEFITS PACKAGE

About this Benefit Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance will replace a portion of your income in the event that you become physically unable to work. Short term disability coverage provides benefits when you are unable to work for a short period of time due to a covered sickness or injury.

DID YOU KNOW?

60% of Americans do not have a “rainy day� fund to cover three months of unanticipated financial emergencies.

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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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


Short Term Disability Weekly Benefit

Total Disability

60% of weekly salary up to $500 per week

Due to an injury or illness, you are unable to perform each of the main duties of your regular occupation.

Elimination Period (Accident/Illness) Benefits begin on: 15th day/15th day

Maximum Duration 11 weeks

Pre-Existing Condition You may not be eligible for benefits if you have received treatment for a condition within 3 months prior to your effective date under this policy until you have been covered under the policy for 6 months.

Partial Disability Due to an injury or illness, you are unable to perform each of the main duties of your regular occupation on a full-time basis. Partial Disability benefits may be payable if you are earning at least 20% of the income you earned prior to becoming disabled, but not more than 99%. Partial disability benefits allow you to work and earn income from your employer as well as continue to receive benefits, which may enable you to receive 100% of your income during your time of disability.

Continuation of Disability

Integration of Benefits Your benefits may be reduced by benefits received from state disability or worker's compensation programs. The total of all benefits received from this policy, state disability plans, worker's compensation programs and your employer's sick pay plan may not exceed 100% of your income prior to disability .

Waiver of Premium You will not be required to pay premium during any time of approved total or partial disability.

Additional Benefits Survivor Income Benefit Rehabilitation Assistance Benefit Portability See the Schedule of Benefits on your Certificate for more information

If you return to work full-time but become disabled from the same disability within 2 weeks of returning to work, you will begin receiving benefits again immediately.

Pre-Existing Condition Any sickness or injury for which you have received medical treatment, consultation, care, or services (including diagnostic measures or the taking of prescribed medications) during the specified months prior to your coverage effective date. A disability arising from any such sickness or injury will be covered only if it begins after you have performed your regular occupation on a full-time basis for the specified months following the coverage effective date.

Benefit Exclusions

All employees in an eligible class. You are able to take advantage of this coverage now without a health examination. You may not be offered this opportunity again until your annual open enrollment.

You will not receive benefits in the following circumstances:  Your disability is the result of a self-inflicted injury.  You are not under the regular care of a doctor when requesting disability benefits.  Your disability is covered under a worker’s compensation plan and/or is due to a job-related sickness or injury.

Monthly Premium Cost

Benefit Reductions

Eligibility

Age

Rates per $10 of weekly benefit

<24

$.297

25-29

$.297

30-34

$.286

35-39

$.286

40-44

$.310

45-49

$.363

50-54

$.429

55-59

$.565

60-64

$.693

65-69

$.781

70-99

$.950

Your benefits may be reduced if you are receiving benefits from any of the following sources:  Any governmental retirement system earned as a result of working for the current policyholder;  Any disability or retirement benefit received under a retirement plan;  Any Social Security, or similar plan or act, benefits;  Earnings the insured earns or receives from any form of employment;  Disability income benefits received under state disability benefit laws.

Coverage Termination This coverage will terminate when you terminate employment with this policyholder, or at your retirement.

23


AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

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.

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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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


GC3 Limited Benefit Group Cancer Indemnity Insurance City of Mount Pleasant

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 NONSUBSCRIBERS 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

Riders Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

$50; 1 person, per calendar year

Critical Illness Rider: Heart Attack/Stroke & 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

Optional Benefit Rider Intensive Care Unit Rider Semi-Monthly Premium**

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$8.15

$9.80

$16.20

$17.85

One Parent

$11.40

$13.65

$22.30

$24.55

Two Parent

$14.50

$17.95

$28.30

$31.75

*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 City of Mount Pleasant ISD-0315 (Semi-Monthly)

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GC3 Limited Benefit Group Cancer Indemnity Insurance Eligibility

Diagnostic Testing Benefit Rider

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.

Critical Illness Rider

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.

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.

APSB-22356(TX) MGM/FBS City of Mount Pleasant ISD-0315 (Semi-Monthly) 26

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.

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 preexisting 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 ten-month 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 thirtyone (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

This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and 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) | City of Mount Pleasant | Semi-Monthly

APSB-22356(TX) MGM/FBS City of Mount Pleasant ISD-0315 (Semi-Monthly)

27


AUL A ONEAMERICA COMPANY 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.

28

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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


Life and AD&D Group Term Life Including matching AD&D Coverage    

Life and AD&D insurance coverage amount of $15,000 at no cost to you Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns

Eligible Employees This benefit is available for employees who are actively at work on the effective date and working a minimum of 30 hours per week.

Flexible Choices Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.

Guaranteed Issue Amounts This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability. If you have current coverage, you can increase $10,000 each year up to the Guaranteed Issue without completing an Evidence of Insurability. New Hires can elect up to the Guaranteed Issue without Evidence of Insurability.

Continuation of Coverage Options Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70. OR Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.

Accelerated Life Benefit If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

Waiver of Premium If approved, this benefit waives your insurance premium in case you become totally disabled and are unable to collect a paycheck.

Employee under age 60 - $100,000, Age 60-69 - $20,000, Age 70+ - None Spouse under age 70 - $20,000 (if they have elected $10,000), Age 70+ - None Child - $10,000

Timely Enrollment Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

Evidence of Insurability If you elect a benefit amount over the Guaranteed Issue Amount shown above, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you will be approved or declined for insurance coverage by AUL.

29


Life and AD&D Voluntary Term Life Coverage Monthly Payroll Deduction Illustration About your benefit options:    

You may select a minimum Life benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000, not to exceed 5 times your annual base salary only, rounded to the next higher $1,000. Life amounts requested above $100,000 for an Employee under age 60, $20,000 ages 60-69, $20,000 for a Spouse under age 70, or any amount not requested timely will require Evidence of Insurability. Employee must select coverage to select any Dependent coverage. Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 10/01) Life & AD&D

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.80

$.80

$.80

$.80

$1.20

$1.90

$2.80

$4.80

$8.20

$12.90

$20.03

$32.30

$57.20

$20,000

$1.60

$1.60

$1.60

$1.60

$2.40

$3.80

$5.60

$9.60

$16.40

$25.80

$40.06

$64.60

$114.40

$30,000

$2.40

$2.40

$2.40

$2.40

$3.60

$5.70

$8.40

$14.40

$24.60

$38.70

$60.09

$96.90

$171.60

$40,000

$3.20

$3.20

$3.20

$3.20

$4.80

$7.60

$11.20

$19.20

$32.80

$51.60

$80.12

$129.20 $228.80

$50,000

$4.00

$4.00

$4.00

$4.00

$6.00

$9.50

$14.00

$24.00

$41.00

$64.50

$100.15 $161.50 $286.00

$60,000

$4.80

$4.80

$4.80

$4.80

$7.20

$11.40

$16.80

$28.80

$49.20

$77.40

$120.18 $193.80 $343.20

$70,000

$5.60

$5.60

$5.60

$5.60

$8.40

$13.30

$19.60

$33.60

$57.40

$90.30

$140.21 $226.10 $400.40

$80,000

$6.40

$6.40

$6.40

$6.40

$9.60

$15.20

$22.40

$38.40

$65.60

$103.20 $160.24 $258.40 $457.60

$90,000

$7.20

$7.20

$7.20

$7.20

$10.80

$17.10

$25.20

$43.20

$73.80

$116.10 $180.27 $290.70 $514.80

$100,000

$8.00

$8.00

$8.00

$8.00

$12.00

$19.00

$28.00

$48.00

$82.00

$129.00 $200.30 $323.00 $572.00

SPOUSE ONLY OPTIONS (based on Employee's Age as of 10/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.80

$.80

$.80

$.80

$1.20

$1.90

$2.80

$4.80

$8.20

$12.90

$20.03

$32.30

$57.20

$20,000

$1.60

$1.60

$1.60

$1.60

$2.40

$3.80

$5.60

$9.60

$16.40

$25.80

$40.06

$64.60

$114.40

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Child(ren) 6 months to age 26 Option 1:

30

$10,000

Child(ren) live birth to 6 months $1,000

Monthly Payroll Deduction Life Amount $2.00


Life and AD&D

31


AUL A ONEAMERICA COMPANY YOUR BENEFITS PACKAGE

EAP (Employee Assistance Program)

About this Benefit An Employee Assistance Plan (EAP) is an employee benefit program offered to help employees manage personal and professional problems that might adversely impact their work performance, health, and well-being. Employee Assistance Plans generally include short-term counseling and referral services for employees and their household members. Your Employee Assistance Program benefit is provided to you by your employer.

32

DID YOU KNOW?

38%

of employees have missed life events because of bad work-life balance.

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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


ComPsych GuidanceResources® Program Personal issues, planning for life events or simply managing daily life can affect your work, health and family. Your GuidanceResources program provides support, resources and information for personal and work-life issues. The program is company-sponsored, confidential and provided at no charge to you and your dependents. This flyer explains how GuidanceResources can help you and your family deal with everyday challenges.

Work-Life Solutions

Confidential Counseling

GuidanceResources Online is your one stop for expert information on the issues that matter most to you...relationships, work, school, children, wellness, legal, financial, free time and more. › Timely articles, HelpSheetsSM, tutorials, streaming videos and self-assessments › “Ask the Expert” personal responses to your questions › Child care, elder care, attorney and financial planner searches

This no-cost counseling service helps you address stress, relationship and other personal issues you and your family may face. It is staffed by GuidanceConsultantsSM—highly trained master’s and doctoral level clinicians who will listen to your concerns and quickly refer you to in-person counseling (up to 3 sessions per issue per year) and other resources for: › Stress, anxiety and depression › Job pressures › Relationship/marital conflicts › Grief and loss › Problems with children › Substance abuse

Financial Information and Resources Speak by phone with our Certified Public Accountants and Certified Financial Planners on a wide range of financial issues including: › Getting out of debt › Retirement planning › Credit card or loan problems › Estate planning › Tax questions › Saving for college

Legal Support and Resources Talk to our attorneys by phone. If you require representation, we’ll refer you to a qualified attorney in your area for a free 30-minute consultation with a 25% reduction in customary legal fees thereafter. Call about: › Divorce and family law › Real estate transactions › Debt and bankruptcy › Civil and criminal actions › Landlord/tenant issues › Contracts

Our Work-Life specialists will do the research for you, providing qualified referrals and customized resources for: › Child and elder care › College planning › Moving and relocation › Pet care › Making major purchases › Home repair

GuidanceResources® Online

Free Online Will Preparation EstateGuidance® lets you quickly and easily write a will on your computer. Just go to www.guidanceresources.com and click on the EstateGuidance link. Follow the prompts to create and download your will at no cost. Online support and instructions for executing and filing your will are included. You can: › Name an executor to manage your estate › Choose a guardian for your children › Specify your wishes for your property › Provide funeral and burial instructions

Call Anytime Call: (855) 387-9727 TDD: (800) 697-0353 Online: www.guidanceresources.com Your company web ID: ONEAMERICA3

Program starts January 1, 2016.

OneAmerica is the marketing name for American United Life Insurance Company® (AUL). AUL markets ComPsych services. ComPsych Corporation is not an affiliate of AUL and is not a OneAmerica company.

33


5STAR

Individual Life

YOUR BENEFITS PACKAGE

About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

DID YOU KNOW? Experts recommend at least

x 10 your gross annual income in coverage when purchasing life insurance.

34

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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


Individual Life with Critical Illness The Family Protection Plan Term life insurance with Critical Illness coverage to age 100 This insurance is a voluntary benefit that is being provided through your employer to complement your overall benefit package. Most people are not prepared for the financial devastation that frequently accompanies death or the survival of a critical illness. The Family Protection Plan was developed to provide term life insurance protection and an instant emergency fund if an unexpected critical illness occurs, to age 100*. 

 

  

Term Insurance to Age 100. Offers a guaranteed level premium to age 100 and a guaranteed level death benefit for the first 10 years. After 10 years the death benefit is projected to remain level to age 100 and we do not anticipate a reduction in the future. The coverage amount cannot be individually decreased on a particular insured due to a change in age, health, or employment status. Critical Illness Benefit pays the insured 30% of the policy coverage amount in a lump sum upon the occurrence of heart attack, life threatening cancer, stroke, cardiac bypass or heart transplant surgery or a terminal condition. Portability. You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. Family Protection. Individual policies can be purchased on the employee, spouse, children and grandchildren. Children and Grandchildren Plan. Policies can also be purchased for children and grandchildren ages newborn through 23 for $4.33/month for a $10,000 policy or $8.67/month for a $20,000 policy. Convenience. Premiums are taken care of simply and easily through payroll deductions. Easy Application Process. This insurance does not require a medical exam or blood profile. Eligibility for coverage is based on a few simple health questions on the application. Emergency Burial Benefit. Within 24 hours after receiving notice of an insured's death, an emergency death benefit of the lesser of 50% of the coverage amount, or $15,000 will be mailed to the insured's beneficiary, unless the death is within the two-year contestability period and/or under investigation.

The Family Protection Plan Covered Critical Illnesses Covered critical illnesses include:  Heart Attack  Life-Threatening Cancer  Stroke  Cardiac Bypass Surgery  Heart Transplant Surgery This benefit is also paid for terminal conditions

DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.

The Benefits of Critical Illness Coverage More people are suffering from a critical illness than ever before. Chances are you have seen first hand the financial hardship that either a relative, close friend, or co-worker has had to endure during the recovery process of a critical illness. Most employee benefits plans are designed to cover specific expenses. But, The Family Protection Plan pays a one-time lump sum of 30% (25% in Michigan) of the policy benefit in cash directly to the owner-in addition to any other insurance plan the insured may have! There are no restrictions on how this benefit is used. *Age 95 in Maryland and Utah. Not available in all states.

35


Individual Life with Critical Illness $6

$7

$8

$9

$10

$11

$12

Age on Critical Critical Critical Critical Critical Critical Critical Coverage Coverage Coverage Coverage Coverage Coverage Coverage App. Illness Illness Illness Illness Illness Illness Illness Amount Amount Amount Amount Amount Amount Amount Date Benefits Benefits Benefits Benefits Benefits Benefits Benefits 18-25 $55,319 $16,596 $66,383 $19,915 $77,447 $23,234 $88,511 $26,553 $99,574 $29,872 $110,638 $33,191 $121,702 $36,511

36

26

$54,968 $16,490 $65,962 $19,789 $76,956 $23,087 $87,949 $26,385 $98,943 $29,683 $109,937 $32,981 $120,930 $36,279

27

$54,167 $16,250 $65,000 $19,500 $75,833 $22,750 $86,667 $26,000 $97,500 $29,250 $108,333 $32,500 $119,167 $35,750

28

$52,953 $15,886 $63,544 $19,063 $74,134 $22,240 $84,725 $25,418 $95,316 $28,595 $105,906 $31,772 $116,497 $34,949

29

$51,485 $15,446 $61,782 $18,535 $72,079 $21,624 $82,376 $24,713 $92,673 $27,802 $102,970 $30,891 $113,267 $33,980

30

$49,808 $14,942 $59,770 $17,931 $69,732 $20,920 $79,693 $23,908 $89,655 $26,897 $99,617 $29,885 $109,579 $32,874

31

$48,237 $14,471 $57,885 $17,366 $67,532 $20,260 $77,180 $23,154 $86,827 $26,048 $96,475 $28,943 $106,122 $31,837

32

$46,763 $14,029 $56,115 $16,835 $65,468 $19,640 $74,820 $22,446 $84,173 $25,252 $93,525 $28,058 $102,878 $30,863

33

$45,217 $13,565 $54,261 $16,278 $63,304 $18,991 $72,348 $21,704 $81,391 $24,417 $90,435 $27,131 $99,478 $29,843

34

$43,478 $13,043 $52,174 $15,652 $60,870 $18,261 $69,565 $20,870 $78,261 $23,478 $86,957 $26,087 $95,652 $28,696

35

$41,534 $12,460 $49,840 $14,952 $58,147 $17,444 $66,454 $19,936 $74,760 $22,428 $83,067 $24,920 $91,374 $27,412

36

$39,157 $11,747 $46,988 $14,096 $54,819 $16,446 $62,651 $18,795 $70,482 $21,145 $78,313 $23,494 $86,145 $25,844

37

$36,517 $10,955 $43,820 $13,146 $51,124 $15,337 $58,427 $17,528 $65,730 $19,719 $73,034 $21,910 $80,337 $24,101

38

$33,766 $10,130 $40,519 $12,156 $47,273 $14,182 $54,026 $16,208 $60,779 $18,234 $67,532 $20,260 $74,286 $22,286

39

$31,026 $9,308 $37,232 $11,170 $43,437 $13,031 $49,642 $14,893 $55,847 $16,754 $62,053 $18,616 $68,258 $20,477

40

$28,509 $8,553 $34,211 $10,263 $39,912 $11,974 $45,614 $13,684 $51,316 $15,395 $57,018 $17,105 $62,719 $18,816

41

$26,369 $7,911 $31,643 $9,493 $36,917 $11,075 $42,191 $12,657 $47,465 $14,240 $52,738 $15,821 $58,012 $17,404

42

$24,505 $7,352 $29,406 $8,822 $34,307 $10,292 $39,208 $11,762 $44,109 $13,233 $49,010 $14,703 $53,911 $16,173

43

$22,847 $6,854 $27,417 $8,225 $31,986 $9,596 $36,555 $10,967 $41,125 $12,338 $45,694 $13,708 $50,264 $15,079

44

$21,346 $6,404 $25,616 $7,685 $29,885 $8,966 $34,154 $10,246 $38,424 $11,527 $42,693 $12,808 $46,962 $14,089

45

$19,954 $5,986 $23,945 $7,184 $27,936 $8,381 $31,926 $9,578 $35,917 $10,775 $39,908 $11,972 $43,899 $13,170

46

$18,638 $5,591 $22,366 $6,710 $26,093 $7,828 $29,821 $8,946 $33,548 $10,064 $37,276 $11,183 $41,004 $12,301

47

$17,391 $5,217 $20,870 $6,261 $24,348 $7,304 $27,826 $8,348 $31,304 $9,391 $34,783 $10,435 $38,261 $11,478

48

$16,240 $4,872 $19,488 $5,846 $22,736 $6,821 $25,984 $7,795 $29,232 $8,770 $32,480 $9,744 $35,728 $10,718

49

$15,196 $4,559 $18,235 $5,471 $21,274 $6,382 $24,313 $7,294 $27,352 $8,206 $30,392 $9,118 $33,431 $10,029

50

$14,254 $4,276 $17,105 $5,132 $19,956 $5,987 $22,807 $6,842 $25,658 $7,697 $28,509 $8,553 $31,360 $9,408

51

$13,402 $4,021 $16,082 $4,825 $18,763 $5,629 $21,443 $6,433 $24,124 $7,237 $26,804 $8,041 $29,485 $8,846

52

$12,621 $3,786 $15,146 $4,544 $17,670 $5,301 $20,194 $6,058 $22,718 $6,815 $25,243 $7,573 $27,767 $8,330

53

$11,888 $3,566 $14,266 $4,280 $16,644 $4,993 $19,021 $5,706 $21,399 $6,420 $23,777 $7,133 $26,155 $7,847

54

$11,188 $3,356 $13,425 $4,028 $15,663 $4,699 $17,900 $5,370 $20,138 $6,041 $22,375 $6,713 $24,613 $7,384

55

$10,505 $3,152 $12,606 $3,782 $14,707 $4,412 $16,808 $5,042 $18,909 $5,673 $21,010 $6,303 $23,111 $6,933


Individual Life with Critical Illness $6

$7

$8

$9

$10

$11

$12

Age on Critical Critical Critical Critical Critical Critical Critical Coverage Coverage Coverage Coverage Coverage Coverage Coverage App. Illness Illness Illness Illness Illness Illness Illness Amount Amount Amount Amount Amount Amount Amount Date Benefits Benefits Benefits Benefits Benefits Benefits Benefits 56

$9,837

$2,951 $11,805 $3,542 $13,772 $4,132 $15,740 $4,722 $17,707 $5,312 $19,675 $5,903 $21,642 $6,493

57

$9,194

$2,758 $11,033 $3,310 $12,871 $3,861 $14,710 $4,413 $16,549 $4,965 $18,388 $5,516 $20,226 $6,068

58

$8,587

$2,576 $10,304 $3,091 $12,021 $3,606 $13,738 $4,121 $15,456 $4,637 $17,173 $5,152 $18,890 $5,667

59

$8,022

$2,407

$9,627

$2,888 $11,231 $3,369 $12,836 $3,851 $14,440 $4,332 $16,044 $4,813 $17,649 $5,295

60

$7,506

$2,252

$9,007

$2,702 $10,508 $3,152 $12,009 $3,603 $13,510 $4,053 $15,012 $4,504 $16,513 $4,954

61

$7,042

$2,113

$8,451

$2,535

$9,859

$2,958 $11,268 $3,380 $12,676 $3,803 $14,085 $4,226 $15,493 $4,648

62

$6,624

$1,987

$7,949

$2,385

$9,274

$2,782 $10,599 $3,180 $11,924 $3,577 $13,248 $3,974 $14,573 $4,372

63

$6,242

$1,873

$7,491

$2,247

$8,739

$2,622

$9,988

$2,996 $11,236 $3,371 $12,485 $3,746 $13,733 $4,120

64

$7,067

$2,120

$8,245

$2,474

$9,422

$2,827 $10,600 $3,180 $11,778 $3,533 $12,956 $3,887

65

$6,655

$1,997

$7,765

$2,330

$8,874

$2,662

$9,983

$2,995 $11,092 $3,328 $12,201 $3,660

66

$6,239

$1,872

$7,279

$2,184

$8,318

$2,495

$9,358

$2,807 $10,398 $3,119 $11,438 $3,431

67

$6,767

$2,030

$7,734

$2,320

$8,701

$2,610

$9,667

$2,900 $10,634 $3,190

68

$6,220

$1,866

$7,109

$2,133

$7,997

$2,399

$8,886

$2,666

$9,774

$2,932

$6,455

$1,937

$7,261

$2,178

$8,068

$2,420

$8,875

$2,663

$6,511

$1,953

$7,234

$2,170

$7,958

$2,387

69 70

$1.15 weekly Available only on children and grandchildren of employee:

$2.30 weekly

Age on App. Date

Coverage Amount

Critical Illness Benefits

Coverage Amount

Critical Illness Benefits

Full-Term Newborn to 23 years

$10,000

$3,000

$20,000

$6,000

37


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.

38

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.

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 City of Mount Pleasant Benefits Website: www.mybenefitshub.com/cityofmtpleasant


FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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.

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September.

NBS Prepaid MasterCard® Debit Card

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.

Don’t forget, Flex Cards Are Good For 3 Years!

For a list of sample expenses, please refer to the City of Mount Pleasant benefit website: www.mybenefitshub.com/ cityofmtpleasant

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

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.

FSA Annual Contribution Max:

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

$2,550

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 account balances Claim forms, Direct Deposit form, worksheets, etc. Online claims FAQs

39


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/cityofmtpleasant

40

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (September 30th)? 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/ cityofmtpleasant 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 after the Plan year ends for you to submit qualified claims for any unused funds.

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www.mybenefitshub.com/cityofmtpleasant

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