2017 Benefit Guide - Keller ISD

KELLER ISD

BENEFIT GUIDE EFFECTIVE: 01/01/2017 - 12/31/2017 www.mybenefitshub.com/kellerisd

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Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. KISD Frequently Asked Questions 7. KISD Rates The Hartford Basic Life UnitedHealthcare Medical Voya Hospital Indemnity Voya Critical Illness Voya Accident Cigna Dental Superior Vision QCD Discount Dental & Vision The Hartford Long Term Disability The Hartford Voluntary Life and AD&D NBS Flexible Spending Account (FSA)

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3 4-5 6-11 6 7 8 9 10 11 12-15 16-17 18-29 30-33 34-37 38-41 42-47 48-49 50-51 52-55 56-61 62-65

FLIP TO...

PG. 4 HOW TO ENROLL

PG. 6 BENEFIT UPDATES: WHAT’S NEW

PG. 12 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information KELLER ISD BENEFITS

DENTAL

FLEXIBLE SPENDING ACCOUNT

Financial Benefit Services (469) 385-4685 www.mybenefitshub.com/kellerisd

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

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

KELLER ISD BENEFITS OFFICE

VISION

KELLER POINTE FITNESS PROGRAM

Keller ISD (817) 744-1080 www.kellerisd.net

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

City of Keller (817) 743-4386 www.cityofkeller.com/services/the-kellerpointe

HOSPITAL INDEMNITY

DISCOUNT DENTAL & VISION

MEDICAL

Voya (800) 955-7736 www.voya.com

QCD (800) 229-0304 www.qcdofamerica.com

CRITICAL ILLNESS

LONG TERM DISABILITY

Voya (800) 955-7736 www.voya.com

Policy # 395309 The Hartford (800) 523-2233 File a claim: (866) 278-2655 www.thehartford.com

Group # 715197 United Healthcare (800) 241-1658 www.uhc.com COBRA Services: (877) 797-7475 Member Services: (877) 311-7849 Card Services: (866) 755-2648

ACCIDENT

LIFE AND AD&D

Voya (800) 955-7736 www.voya.com

The Hartford (800) 523-2233 www.thehartford.com

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

TEXT

need to complete your enrollment.

“kellerisd”

Avoid typing long URLs and scan

TO

directly to your benefits website,

313131

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

TRY ME

SCAN:

On Your Computer Access the Keller ISD benefits

Our online benefit enrollment

website from your computer, tablet

platform provides a simple and

or smartphone!

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

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.

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

Benefit elections will become effective 01/01/2017 (elections requiring evidence of insurability, such as life insurance, may have a later effective date, if approved).

After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of the event).



Keller ISD takes their premiums a month in advance, so if you elect benefits during Open Enrollment, your first premium payments will come out of your December paycheck, except for your disability and health care or dependent care FSA premiums. They will start coming out of your January paycheck.



Medical rates are increasing for the 2017 plan year.

There have also been slight changes to your medical plans, please refer to the Medical benefit summary for more details.



Keller ISD is adding a Dental HMO (DHMO) plan effective 1/1/17. If you wish to participate in the DHMO, you must designate a dentist with a dentist ID in THEbenefitsHUB upon enrollment. There are no dollar maximums and services are based on a fee schedule.



If you participate in a Health Care or Dependent Care FSA, you MUST re‐elect a new contribution amount every year to continue to participate. Eligible expenses must be incurred within the plan year and contributions are use‐it‐or lose‐it.



If you completed all activities of the Wellness Incentive Program you will receive a monthly discount on your medical premiums for 2017.



If you need further assistance with your enrollment, please contact:

Yolanda Carter, Benefits Specialist at 817‐744‐1080 or Sheri Rich, Director of Employee Benefits at 817‐744‐1087

Don’t Forget!  Login and complete your benefit enrollment from 10/17/2016—10/31/2017.  Refer to Keller ISD’s Employee Benefit Website “THEbenefitsHUB” for all your benefit plan summaries, rates & options: www.mybenefitshub.com/kellerisd or K-Connect: Functions; Workforce-HR; Benefits.  Due to Affordable Care Act (ACA) every employee must decline or elect benefits during open enrollment.  Update beneficiary information.  Update your profile information: home address, phone numbers, email through the Employee Access Center (EAC).  Update dependent information; social security number & student status for college aged children.

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SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer.

Enrollment is automatic unless you decline this benefit.

Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 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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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website: www.mybenefitshub.com/kellerisd.

annual enrollment) unless a Section 125 qualifying event occurs.

Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the



Changes, additions or drops may be made only during the

Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

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

district’s website: www.mybenefitshub.com/kellerisd. Click on

included in the dependent profile. Additionally, you must

the benefit plan you need information on (i.e., Dental) and

notify your employer of any discrepancy in personal and/or

you can find provider search links under the Quick Links

benefit information.



For benefit summaries and claim forms, go to your school

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

section.

When will I receive ID cards?

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

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

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

Q&A Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services

at 800-583-6908 for assistance.

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 30 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within Keller ISD or as both

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

employees and dependents.

work concurrent with the plan effective date. For example, if your 2017 benefits become effective on January 1, 2017, you must be actively-at-work on January 1, 2017 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

UnitedHealthcare

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Dental

Cigna

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Vision

Superior Vision

26

Hospital Indemnity

Voya

26

Critical Illness

Voya

26

Accident

Voya

26

Voluntary Life and AD&D

The Hartford

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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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SUMMARY PAGES

Helpful Definitions 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 1/1/2017 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 January 1st through December 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).

KISD Frequently Asked Questions 1.

What are the prices for The Keller Pointe passes?

NonResident NonResident Resident with GE Resident with GE Adult

$30.42

$36.67

$38.75

$45.00

Family

$47.92

$54.17

$60.83

$67.08

Senior

$20.83

$27.08

$26.67

$32.92

6.

SUMMARY PAGES

What if I want to purchase a Keller Pointe pass outside of the annual benefit enrollment?

You may register at The Keller Pointe Customer Service Desk, with your KISD badge, and pay monthly through electronic funds transfer using your bank account, Visa or MasterCard and The Keller Pointe will waive the $60 service fee. However, your fee will be the standard published monthly rates for residents at the resident rate or non-residents at the resident business rate. Please

2.

What is the benefit to KISD employees by joining The Keller

contact The Keller Pointe for rates.

Pointe through payroll deduction?

The City of Keller and KISD have an agreement to provide KISD employees annual passes to The Keller Pointe and pay through payroll deduction. Because KISD has agreed to an

annual registration and withdrawal, the rates are discounted from the published monthly rates. Also, the $60.00 service fee has been waived for KISD employees.

3.

Who qualifies as a resident vs. non-resident?

A resident is one who lives within the city limits of the City of Keller. Look at your property tax record and see if you pay City of Keller taxes. Your postal address does not necessarily coincide with your city residency.

4.

What does a family consist of?

Those individuals you claim as your dependent on your tax form, can be placed on your family pass. Be ready to give proof of dependency if asked by The Keller Pointe.

5.

What is a group exercise add-on?

Group exercise add-on allows all members on the pass to participate in both land and water aerobics offered at The Keller Pointe.

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Keller ISD Rates

SUMMARY PAGES

Plan Year January 1, 2017 - December 31, 2017

Keller ISD Medical Plans –United Healthcare Member Line: 800-241-1658 Group #715197 Visit www.myuhc.com for detailed information on covered/non covered items, prescriptions, benefits, as well as to check on claims, and out of pocket maximums.

Keller Independent School District’s Benefit Plan Year is from January 1, 2017 to December 31, 2017 Major Medical Plan 2016 Monthly Rates

2016 Incentive Plan Rates

2017 Monthly Rates

2017 Incentive Plan Rates

Employee Only

$68.88

$48.88

$88.88

$48.88

Employee + Spouse

$515.94

$495.94

$595.94

$555.94

Employee + Child

$259.09

$239.09

$339.09

$299.09

Employee + Children

$354.52

$334.52

$434.52

$394.52

Employee + Family

$870.43

$850.43

$950.43

$910.43

Highlights of the 2017 Major Medical Plan:  $3,000 Individual Deductible/$6,000 Family Deductible  Total Out of Pocket Limit: $6,850 Individual/$13,700 Family  70/30 Coinsurance - once you have met the $3,000/$6,000 deductible, the plan pays 70% of In-Network charges and you pay 30%  Primary Care Physician Copays are $25/$45 and Specialist Copays are $45/$65  There are no Out of Network Benefits  $100 Prescription Deductible - per covered member, per year (deductible does not apply to generic or mail order)  $250 Emergency Room Copay - per visit; $100.00 Urgent Care Center Copay - per visit (ex: Care Now)  100% Wellness Benefit - every covered member receives routine wellness and other preventive care services  100% Lab Benefit - routine lab work done at a participating In-Network lab facility is paid at 100% Essential Medical Plan 2016 Monthly Rates

2016 Incentive Plan Rates

2017 Monthly Rates

2017 Incentive Plan Rates

Employee Only

$176.25

$156.25

$256.25

$216.25

Employee + Spouse

$644.81

$624.81

$724.81

$684.81

Employee + Child

$403.75

$383.75

$483.75

$443.75

Employee + Children

$508.25

$488.25

$588.26

$548.26

$1,067.50

$1,047.50

$1,147.50

$1,107.50

Employee + Family

Highlights of the 2017 Essential Plan:  $1,500 Individual Deductible/$3,000 Family Deductible  Total Out of Pocket Limit: $6,850 Individual/$13,700 Family  70/30 Coinsurance - once you have met the $1,500/$3,000 deductible, the plan pays 70% of In-Network charges and you pay 30%  Primary Care Physician Copays $25/$45 and Specialist Copays $45/$65  There are no Out of Network Benefits  $75 Prescription Deductible - per covered member, per year (deductible does not apply to generic or mail order)  $250 Emergency Room Copay - per visit; $100.00 Urgent Care Center Copay - per visit (ex: Care Now)  100% Wellness Benefit - every covered member receives routine wellness and other preventive care services  100% Lab Benefit - routine lab work done at a participating In-Network lab facility is paid at 100% 12

SUMMARY PAGES

High Option Medical Plan 2016 Monthly Rates

2016 Incentive Plan Rates

2017 Monthly Rates

2017 Incentive Plan Rates

$341.30

$321.30

$421.30

$381.30

$1,044.65

$1,024.65

$1,124.65

$1,084.65

Employee + Child

$587.00

$567.00

$667.00

$627.00

Employee + Children

$749.00

$729.00

$829.00

$789.00

$1,628.50

$1,608.50

$1,708.50

$1,668.50

Employee Only Employee + Spouse

Employee + Family

Highlights of the 2017 High Option Plan:  $750 Individual Deductible/$1,500 Family Deductible  Total Out of Pocket Limit: $6,850 individual/$13,700 family  80/20 Coinsurance (In-Network) - once you have met the $750/$1,500 deductible, the plan pays 80% of In-Network charges and you pay 20%;  50/50 Coinsurance (Out-of-Network) - once you have met the $2,250 Individual/$4,500 Family deductible, the plan pays 50% of Out-of    

Network charges and you pay 50% Primary Care Physician Copays are $25/$45 and Specialist Copays are $45/$65 $50 Prescription Deductible - per covered member, per year (deductible does not apply to generic or mail order) $250 Emergency Room Copay- per visit 100% Wellness Benefit - every covered member receives routine wellness and other preventive care services; In Network only 100% Lab Benefit - routine lab work done at a participating In-Network lab facility is paid at 100%

2016/2017 Dental Insurance: Cigna Low Plan Monthly Rates

High Plan Monthly Rates

DHMO Rates

Employee Only

$28.44

$35.78

$17.44

Employee + Spouse

$55.53

$69.85

$34.02

Employee + Child(ren)

$67.93

$85.42

$41.69

Employee + Family

$89.96

$112.96

$55.12

Highlights of the Dental Insurance Low and High Plans (PPO):  Cleanings – 2 included per year, per covered member (covered at 100% on the High Plan and 90% on the Low Plan)  Child Orthodontia - ONLY covered on the High Plan with a 50% benefit up to Lifetime Max of $1000  Deductible - $50 per individual; $150 per family; in or out of network on both plans Highlights of the DHMO Dental Insurance Plan (New for the 2017 Benefit Plan Year):  No dollar Maximums  No claim forms or waiting periods for coverage to begin  Services based on a fee schedule; most fees are covered with copays  Orthodontic coverage for children and adults with no dollar maximum  Must use a Cigna In-Network DHMO Provider only; No out of network benefits 13

Keller ISD Rates Plan Year January 1, 2017 - December 31, 2017

SUMMARY PAGES

2016/2017 Vision Insurance: Superior Vision Monthly Rates Employee Only

$8.10

Employee + Spouse

$15.70

Employee + Family

$23.08

Highlights of the Vision Insurance Plan:  Vision Exam every 12 months  Either glasses or contact lenses every 12 months  Frames every 12 months  Discounts for anything you choose to purchase in addition to the glasses or contacts every 12 months

2016/2017 Dental & Vision Discount Plan: QCD of America Monthly Rates Employee Only

FREE

Employee + One Dependent

$10.00

Employee + Family

$14.00

Highlights of the QCD of America Discount Dental and Vision Plan:  This is not an insurance plan; it only provides discounted fees.  Participating network of dentists  Discounts on all dental services  Includes a discount vision plan through Davis

2016/2017 Accidental Insurance: Voya Monthly Rates Employee Only

$2.85

Employee + One Dependent

$5.00

Employee + Child(ren)

$6.41

Employee + Family

$8.56

Highlights of the Accidental Insurance Plan:  For each covered individual a set reimbursement is paid for each accident occurrence. This does not apply to work related injuries.  Accident coverage covers child accidental injuries while participating in organized sports  True Annual Open Enrollment without medical question requirement up to guarantee issue amount

2016/2017 In-Hospital Indemnity Insurance – Voya  Insurance pays lump sum benefit amounts based on the number of days spent in a hospital, critical care unit, or rehabilitation facility.  You can use this benefit for any purpose you like and the coverage is portable.  Coverage is available for you, your spouse and/or children.

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SUMMARY PAGES

2016/2017 Critical Illness Insurance: Voya Attained Age

EE Tobacco

EE Non-Tobacco

<25

$0.74

$0.43

25-29

$0.78

$0.45

30-34

$0.92

$0.51

35-39

$1.19

$0.65

40-44

$1.73

$0.92

45-49

$2.59

$1.35

50-54

$3.71

$1.91

55-59

$5.05

$2.61

60-64

$7.07

$3.65

Highlights of the Critical Insurance Plan:  Monthly Rates per $1,000; 100% benefit for recurrence  Cancer is included in this policy  Employees can obtain $20,000 of guaranteed Critical Illness coverage with no medical questions required  Voya’s Critical Illness policy does include a wellness benefit of $50.00 annually 2016/2017 Flexible Spending Accounts: National Benefit Services (NBS)  Tax-sheltered flexible spending accounts allow an individual to set aside dollars to pay for future health care and dependent care expenses.  Monthly fee: $2.85  Health Care Contributions are use-it-or-lose-it  Healthcare reimbursement maximum: $2,400/plan year  Dependent Care Reimbursement maximum: $5,000 (married) or $2,500 (single) per year 2016/2017 Disability Insurance - The Hartford  A disability plan will pay you, based on what you elect, while you are off work due to a disability.  These payments are in addition to pay you may or may not receive through the district.  Choices are as follows: Plan A: Premium Plan

Plan B: Select Plan

Plan A—Injury 0/Sickness 3

Plan B—Injury 0/Sickness 3

Plan A—Injury 14/Sickness 14

Plan B—Injury 14/Sickness 14

Plan A—Injury 30/Sickness 30

Plan B—Injury 30/Sickness 30

Plan A—Injury 60/Sickness 60

Plan B—Injury 60/Sickness 60

Plan A—Injury 90/Sickness 90

Plan B—Injury 90/Sickness 90

Plan A—Injury 180/Sickness 180

Plan B—Injury 180/Sickness 180

  

Plan A is our premium plan and the payment period prior to age 63 is to normal retirement age, for disabilities resulting from sickness or injury.

Plan B is our select plan and the payment period prior to age 63 is to normal retirement age, for disabilities resulting from injury and prior to age 65 is 5 years, for disabilities resulting from sickness.

If you choose an elimination period of 0/3, 14/14 or 30/30 and if you are confined to the hospital for more than 24 hours your elimination period is waived.

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THE HARTFORD

Basic Life and AD&D

YOUR BENEFITS PACKAGE

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.

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DID YOU KNOW? Experts recommend at least

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

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Basic Life and AD&D Benefit Highlights Your Employer provides, at no cost to you, Basic Life and AD&D Insurance in an amount equal to $15,000. Life Insurance pays your beneficiary (please see below) a benefit if you die while you are What is Basic Life and AD&D covered.

This highlight sheet is an overview of your Basic Life and AD&D Insurance. Once a group policy is Insurance? issued to your employer, a certificate of Insurance will be available to explain your coverage in detail.

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

As an eligible Employee, you are automatically covered by Basic Life and AD&D Insurance; you do not have to enroll. If you have not already done so, you must designate a beneficiary as described below.

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.

Benefit Reductions

To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80. All coverage cancels at retirement.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

AD&D Coverage

AD&D provides benefits due to certain injuries or death from an accident. The covered injuries or death can occur up to 365 days after that accident. The insurance pays:  100% of the amount of coverage you purchase in the event of accidental loss of life, two limbs, the sight of both eyes, one limb and the sight of one eye, or speech and hearing in both ears or quadriplegia.  75% for paraplegia or triplegia (paralysis of three limbs).  One-half (50%) for accidental loss of one limb, sight of one eye, or speech or hearing in both ears or hemiplegia.  One-quarter (25%) for accidental loss of thumb and index finger of the same hand or uniplegia.

Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase.

Can I keep my Life Coverage if I leave my employer?

Yes, subject to the contract, you have the option of:  Converting your group Life coverage to your own individual policy (policies).

As is standard with most term life Insurance, this Insurance coverage includes certain limitations and exclusions:  The amount of your coverage may be reduced when you reach certain ages.

Important Details

AD&D insurance does not cover losses caused by or contributed by:  sickness; disease; or any treatment for either;  any infection, except certain ones caused by an accidental cut or wound;  intentionally self-inflicted injury, suicide or suicide attempt;  war or act of war, whether declared or not;  injury sustained while in the armed forces of any country or international authority;  taking prescription or illegal drugs unless prescribed for or administered by a licensed physician;  injury sustained while committing or attempting to commit a felony;  the injured person’s intoxication.

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.

17

UNITEDHEALTHCARE

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Major Medical Plan United HealthCare Services, Inc. and Keller ISD want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:

  

myuhc.com® - Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor and hospital and more.

24-hour nurse support – A nurse is a phone call away and you have other health resources available 24-hours a day, 7 days a week to provide you with information that can help you make informed decisions. Just call the number on the back of your ID card.

Customer Care telephone support – Need more help? Call a customer care professional using the toll-free number on the back of your ID card. Get answers to your benefit questions or receive help looking for a doctor or hospital.

The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

Keller ISD Major Medical Plan 2016 PLAN HIGHLIGHTS Types of Coverage

Network Benefits

Annual Deductible Individual Deductible Family Deductible

$3,000 per year $6,000 per year

 Member Copayments do not accumulate towards the Deductible Out-of-Pocket Maximum Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum

$6,850 per year $13,700 per year

 The Out-of-Pocket Maximum includes the Annual Deductible and any copayment, coinsurance and per occurrence deductible.

Benefit Plan Coinsurance – The Amount the Plan Pays 70% after Deductible has been met.

Lifetime Maximum Benefit There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan.

No Lifetime Maximum Benefit

Prescription Drug Benefits

 Prescription drug benefits are shown under separate cover.

Information of Prior Authorization *Prior Authorization is required for certain services.

Information on Benefit Limits

 The Annual Deductible, Out-of-Pocket Maximum and Benefit limits are calculated on a calendar year basis.  All Benefits are reimbursed based on Eligible Expenses. For a definition of Eligible Expenses, please refer to your Summary Plan Description.  When Benefit limits apply, the limit refers to Network Benefits unless specifically stated in the Benefit category.

19

Major Medical Plan Types of Coverage

Network Benefits

Ambulance Services – Emergency and Non-Emergency * 70% after Deductible has been met.

Dental Services – Accident Only * 70% after Deductible has been met.

Durable Medical Equipment (DME)

1

Benefits are limited as follows: Limited to a single purchase of a type of Durable Medical Equipment (including repair and replacement) every three years. This limit does not apply to wound vacuums.

70% after Deductible has been met.

Emergency Health Services - Outpatient 100% after you pay a $250 Copayment per visit. If you are admitted as an inpatient to a Network Hospital directly from the Emergency room, you will not have to pay this Copayment. The Benefits for an Inpatient Stay in a Network Hospital will apply instead.

Hearing Aids 70% after Deductible has been met.

Home Health Care Benefits are limited as follows: 60 visits per year

70% after Deductible has been met.

Hospice Care 70% after Deductible has been met.

Hospital—Inpatient Stay 70% after Deductible has been met.

Lab, X-Ray and Diagnostics - Outpatient For Preventive Lab, X-Ray and Diagnostics, refer to the Preventive Care Services category.

Labs – 100% of Eligible Expenses.

X-Ray - 70% after Deductible has been met.

Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine - Outpatient 70% after Deductible has been met.

Mental Health Services Inpatient Stay: 70% after Deductible has been met.

Outpatient: 70% after Deductible has been met.

Benefits for outpatient visits for medication management will be paid at 100%.

Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders Inpatient Stay: 70% after Deductible has been met.

Outpatient: 70% after Deductible has been met.

Pharmaceutical Products - Outpatient This includes medications administered in an outpatient setting or in a Covered Person’s home.

70% after Deductible has been met.

Physician Fees for Surgical and Medical Services 70% after Deductible has been met.

Physician’s Office Services - Sickness and Injury

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Primary Physician Office Visit

100% after you pay a $25 Copayment per visit for Premium Designated PCP. 100% after you pay a $45 Copayment per visit for non-Premium Designated PCP.

Specialist Physician Office Visit

100% after you pay a $45 Copayment per visit for Premium Designated Specialist.

100% after you pay a $65 Copayment per visit for non-Premium Designated Specialist.

Major Medical Plan Types of Coverage

Network Benefits

Pregnancy – Maternity Services Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service category in this Benefit Summary.

For services provided in the Physician’s Office, a Copayment will only apply to the initial office visit.

Preventive Care Services Covered Health Services include but are not limited to: Primary Physician Office Visit

100%. Deductible does not apply.

Specialist Physician Office Visit

100%. Deductible does not apply.

Lab, X-Ray or other Preventive Tests

100%. Deductible does not apply.

Prosthetic Devices1 Limited to a single purchase of each type of prosthetic device every three years.

70% after Deductible has been met.

Reconstructive Procedures Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary Rehabilitation Services – Outpatient Therapy and Manipulative Treatment Benefits are limited as follows: 100 combined visits of physical therapy, occupational therapy, speech therapy, pulmonary rehabilitation, and/or cardiac rehabilitation per calendar year.

70% after Deductible has been met.

Scopic Procedures – Outpatient Diagnostic and Therapeutic Diagnostic scopic procedures include, but are not limited to: Colonoscopy; Sigmoidoscopy; Endoscopy.

For Preventive Scopic Procedures, refer to the Preventive Care Services category.

$150 Copayment per occurrence, then 70%. Deductible does not apply.

Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Benefits are limited as follows: 60 days per year

70% after Deductible has been met.

Substance Use Disorder Services Inpatient Stay: 70% after Deductible has been met.

Outpatient: 70% after Deductible has been met.

Benefits for outpatient visits for medication management will be paid at 100%.

Surgery – Outpatient 70% after Deductible has been met.

Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine - Outpatient 70% after Deductible has been met.

Transplantation Services * 70% after Deductible has been met.

For Network Benefits, services must be received at a Designated Facility.

Urgent Care Center Services 100% after you pay a $100 Copayment per visit.

Vision Examinations Benefits are limited as follows: 1 exam every 2 years

100% after you pay a $25 Copayment per visit for Premium Designated PCP. 100% after you pay a $45 Copayment per visit for non-Premium Designated PCP.

1

This benefit category contains services/devices that may be Essential or non-Essential Health Benefits as defined by the Patient Protection and Affordable Care Act depending upon the service or device delivered. A benefit review will take place once the dollar limit is exceeded. If the service/device is determined to be rehabilitative or habilitative in nature, it is an Essential Health Benefit and will be paid. If the benefit/device is determined to be non-essential, the maximum will have been met and the claim will not be paid.

21

Essential Medical Plan United HealthCare Services, Inc. and Keller ISD want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:

  

myuhc.com® - Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor and hospital and more.

24-hour nurse support – A nurse is a phone call away and you have other health resources available 24-hours a day, 7 days a week to provide you with information that can help you make informed decisions. Just call the number on the back of your ID card.

Customer Care telephone support – Need more help? Call a customer care professional using the toll-free number on the back of your ID card. Get answers to your benefit questions or receive help looking for a doctor or hospital.

The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

Keller ISD Essential Medical Plan 2016 PLAN HIGHLIGHTS Types of Coverage

Network Benefits

Annual Deductible Individual Deductible Family Deductible

$1,500 per year $3,000 per year

 Member Copayments do not accumulate towards the Deductible Out-of-Pocket Maximum Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum

$6,850 per year $13,700 per year

 The Out-of-Pocket Maximum includes the Annual Deductible and any copayment, coinsurance and per occurrence deductible.

Benefit Plan Coinsurance – The Amount the Plan Pays 70% after Deductible has been met.

Lifetime Maximum Benefit There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan.

No Lifetime Maximum Benefit

Prescription Drug Benefits

 Prescription drug benefits are shown under separate cover.

Information of Prior Authorization *Prior Authorization is required for certain services.

Information on Benefit Limits

 The Annual Deductible, Out-of-Pocket Maximum and Benefit limits are calculated on a calendar year basis.  All Benefits are reimbursed based on Eligible Expenses. For a definition of Eligible Expenses, please refer to your Summary Plan Description.  When Benefit limits apply, the limit refers to Network Benefits unless specifically stated in the Benefit category.

22

Essential Medical Plan Types of Coverage

Network Benefits

Ambulance Services – Emergency and Non-Emergency * 70% after Deductible has been met.

Dental Services – Accident Only * 70% after Deductible has been met.

Durable Medical Equipment (DME)

1

Benefits are limited as follows: Limited to a single purchase of a type of Durable Medical Equipment (including repair and replacement) every three years. This limit does not apply to wound vacuums.

70% after Deductible has been met.

Emergency Health Services - Outpatient 100% after you pay a $250 Copayment per visit. If you are admitted as an inpatient to a Network Hospital directly from the Emergency room, you will not have to pay this Copayment. The Benefits for an Inpatient Stay in a Network Hospital will apply instead.

Hearing Aids 70% after Deductible has been met.

Home Health Care Benefits are limited as follows: 60 visits per year

70% after Deductible has been met.

Hospice Care 70% after Deductible has been met.

Hospital—Inpatient Stay $150 Copayment per admission, then 70%. Deductible does not apply.

Lab, X-Ray and Diagnostics - Outpatient For Preventive Lab, X-Ray and Diagnostics, refer to the Preventive Care Services category.

Labs - 100% of Eligible Expenses.

X-ray - $150 Copayment per occurrence, then 70%. Deductible does not apply.

Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine - Outpatient Free Standing Facility: $150 Copayment, then 70%.

Hospital Facility: $250 Copayment, then 50%.

Mental Health Services Inpatient Stay: $150 Copayment per admission then 70%. Deductible does not apply.

Outpatient: 70% after Deductible has been met.

Benefits for outpatient visits for medication management will be paid at 100%.

Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders Inpatient Stay: $150 Copayment per admission then 70%. Deductible does not apply.

Outpatient: 70% after Deductible has been met.

Pharmaceutical Products - Outpatient This includes medications administered in an outpatient setting or in a Covered Person’s home.

70% after Deductible has been met.

Physician Fees for Surgical and Medical Services 70% after Deductible has been met.

Physician’s Office Services - Sickness and Injury Primary Physician Office Visit

100% after you pay a $25 Copayment per visit for Premium Designated PCP. 100% after you pay a $45 Copayment per visit for non-Premium Designated PCP.

Specialist Physician Office Visit

100% after you pay a $45 Copayment per visit for Premium Designated Specialist.

100% after you pay a $65 Copayment per visit for non-Premium Designated Specialist.

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Essential Medical Plan Types of Coverage

Network Benefits

Pregnancy – Maternity Services Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service category in this Benefit Summary.

For services provided in the Physician’s Office, a Copayment will only apply to the initial office visit.

Preventive Care Services Covered Health Services include but are not limited to: Primary Physician Office Visit

100%. Deductible does not apply.

Specialist Physician Office Visit

100%. Deductible does not apply.

Lab, X-Ray or other Preventive Tests

100%. Deductible does not apply.

Prosthetic Devices

1

Limited to a single purchase of each type of prosthetic device every three years.

70% after Deductible has been met.

Reconstructive Procedures Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary Rehabilitation Services – Outpatient Therapy and Manipulative Treatment Benefits are limited as follows: 100 combined visits of physical therapy, occupational therapy, speech therapy, pulmonary rehabilitation, and/or cardiac rehabilitation per calendar year.

70% after Deductible has been met.

Scopic Procedures – Outpatient Diagnostic and Therapeutic Diagnostic scopic procedures include, but are not limited to: Colonoscopy; Sigmoidoscopy; Endoscopy.

For Preventive Scopic Procedures, refer to the Preventive Care Services category.

$150 Copayment per occurrence, then 70%. Deductible does not apply.

Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Benefits are limited as follows: 60 days per year

70% after Deductible has been met.

Substance Use Disorder Services Inpatient Stay: $150 Copayment per admission, then 70%. Deductible does not apply.

Outpatient: 70% after Deductible has been met.

Benefits for outpatient visits for medication management will be paid at 100%.

Surgery – Outpatient $150 copay per admission, then 70%. Deductible does not apply.

Transplantation Services * $150 Copayment per Inpatient Stay, then 70%. Deductible does not apply.

For Network Benefits, services must be received at a Designated Facility.

Urgent Care Center Services 100% after you pay a $100 Copayment per visit.

Vision Examinations Benefits are limited as follows: 1 exam every 2 years 1

100% after you pay a $25 Copayment per visit for Premium Designated PCP. 100% after you pay a $45 Copayment per visit for non-Premium Designated PCP.

This benefit category contains services/devices that may be Essential or non-Essential Health Benefits as defined by the Patient Protection and Affordable Care Act depending upon the service or device delivered. A benefit review will take place once the dollar limit is exceeded. If the service/device is determined to be rehabilitative or habilitative in nature, it is an Essential Health Benefit and will be paid. If the benefit/device is determined to be non-essential, the maximum will have been met and the claim will not be paid.

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High Option Medical Plan United HealthCare Services, Inc. and Keller ISD want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:

  

myuhc.com® - Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor and hospital and more.

24-hour nurse support – A nurse is a phone call away and you have other health resources available 24-hours a day, 7 days a week to provide you with information that can help you make informed decisions. Just call the number on the back of your ID card.

Customer Care telephone support – Need more help? Call a customer care professional using the toll-free number on the back of your ID card. Get answers to your benefit questions or receive help looking for a doctor or hospital.

The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

Keller ISD High Option Medical Plan 2016 PLAN HIGHLIGHTS Types of Coverage

Network Benefits

Non-Network Benefits

Annual Deductible Individual Deductible Family Deductible

$750 per year $1,500 per year

$2,250 per year $4,500 per year

 Member Copayments do not accumulate towards the Deductible Out-of-Pocket Maximum Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum

$6,850 per year $13,700 per year

Unlimited

 The Out-of-Pocket Maximum includes the Annual Deductible and any copayment, coinsurance and per occurrence deductible.

Benefit Plan Coinsurance – The Amount the Plan Pays 80% after Deductible has been met.

50% after Deductible has been met.

No Lifetime Maximum Benefit

No Lifetime Maximum Benefit

Lifetime Maximum Benefit There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan.

Prescription Drug Benefits

 Prescription drug benefits are shown under separate cover.

Information of Prior Authorization *Prior Authorization is required for certain services. (Note that only genetic testing for BRCA requires prior authorization for Non-Network services under the Physician’s Services category) **Prior Authorization is required for Equipment in excess of $1,000.

Information on Benefit Limits

 The Annual Deductible, Out-of-Pocket Maximum and Benefit limits are calculated on a calendar year basis.  All Benefits are reimbursed based on Eligible Expenses. For a definition of Eligible Expenses, please refer to your Summary Plan Description.  When Benefit limits apply, the limit refers to Network Benefits unless specifically stated in the Benefit category.

25

High Option Medical Plan Types of Coverage

Network Benefits

Non-Network Benefits

Ambulance Services – Emergency and Non-Emergency * 80% after Deductible has been met.

* 80% after Deductible has been met.

* 80% after Deductible has been met.

* 80% after Deductible has been met.

80% after Deductible has been met.

** 50% after Deductible has been met.

100% after you pay a $250 Copayment per visit. If you are admitted as an inpatient to a Network Hospital directly from the Emergency room, you will not have to pay this Copayment. The Benefits for an Inpatient Stay in a Network Hospital will apply instead.

* 100% after you pay a $250 Copayment per visit.

80% after Deductible has been met.

50% after Deductible has been met.

80% after Deductible has been met.

* 50% after Deductible has been met.

80% after Deductible has been met.

* 50% after Deductible has been met.

$150 copay per admission, then 80%. Deductible does not apply.

* 50% after Deductible has been met.

Labs - 100% of Eligible Expenses.

X-Ray - $150 copay per occurrence, then 80%.

Deductible does not apply

50% after Deductible has been met.

Dental Services – Accident Only Durable Medical Equipment (DME) 1 Benefits are limited as follows: Limited to a single purchase of a type of Durable Medical Equipment (including repair and replacement) every three years. This limit does not apply to wound vacuums.

Emergency Health Services - Outpatient

Hearing Aids

Home Health Care Benefits are limited as follows: 60 visits per year Hospice Care

Hospital—Inpatient Stay

Lab, X-Ray and Diagnostics - Outpatient For Preventive Lab, X-Ray and Diagnostics, refer to the Preventive Care Services category.

Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine - Outpatient Free Standing Facility: $150 copay, then 80%.

Hospital Facility: $250 copay, then 60%.

50% after Deductible has been met.

Mental Health Services Inpatient Stay: $150 copay per admission, then 80%.

Deductible does not apply.

Outpatient: 80% after Deductible has been met. * 50% after Deductible has been met.

Benefits for outpatient visits for medication management will be paid at 100%.

Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders Inpatient Stay: $150 copay per admission, then 80%.

Deductible does not apply.

50% after Deductible has been met.

Outpatient: 80% after Deductible has been met.

Pharmaceutical Products - Outpatient This includes medications administered in an outpatient setting or in a Covered Person’s home.

80% after Deductible has been met.

50% after Deductible has been met.

80% after Deductible has been met.

50% after Deductible has been met.

Primary Physician Office Visit

100% after you pay a $25 Copayment per visit for Premium Designated PCP. 100% after you pay a $45 Copayment per visit for non-Premium Designated PCP.

* 50% after Deductible has been met.

Specialist Physician Office Visit

100% after you pay a $45 Copayment per visit for Premium Designated Specialist.

100% after you pay a $65 Copayment per visit for non-Premium Designated Specialist.

* 50% after Deductible has been met.

Physician Fees for Surgical and Medical Services

Physician’s Office Services - Sickness and Injury

26

High Option Medical Plan Types of Coverage

Network Benefits

Non-Network Benefits

Pregnancy – Maternity Services Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service category in this Benefit Summary.

For services provided in the Physician’s Office, a Copayment will only apply to the initial office visit.

Prior Authorization is required if Inpatient Stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.

Preventive Care Services Covered Health Services include but are not limited to: Primary Physician Office Visit

100%. Deductible does not apply.

Specialist Physician Office Visit

100%. Deductible does not apply.

Lab, X-Ray or other Preventive Tests

100%. Deductible does not apply.

Non-Network Benefits are not available.

Prosthetic Devices1 Limited to a single purchase of each type of prosthetic device every three years.

80% after Deductible has been met.

50% after Deductible has been met.

Reconstructive Procedures Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary Prior Authorization is required for certain services.

Rehabilitation Services – Outpatient Therapy and Manipulative Treatment Benefits are limited as follows: 100 combined visits of physical therapy, occupational therapy, speech therapy, pulmonary rehabilitation, and/or cardiac rehabilitation per calendar year.

80% after Deductible has been met.

* 50% after Deductible has been met.

Scopic Procedures – Outpatient Diagnostic and Therapeutic Diagnostic scopic procedures include, but are not limited to: Colonoscopy; Sigmoidoscopy; Endoscopy. $150 Copayment per occurrence, then 80%.

For Preventive Scopic Procedures, refer to the Deductible does not apply.

Preventive Care Services category.

50% after Deductible has been met.

Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Benefits are limited as follows: 60 days per year

80% after Deductible has been met.

* 50% after Deductible has been met.

Substance Use Disorder Services Inpatient Stay: $150 Copayment per admission, then 80%. Deductible does not apply.

Outpatient: 80% after Deductible has been met. * 50% after Deductible has been met.

Benefits for outpatient visits for medication management will be paid at 100%.

Surgery – Outpatient $150 Copayment per admission, then 80%.

Deductible does not apply.

* 50% after Deductible has been met.

Transplantation Services 80% after Deductible has been met.

For Network Benefits, services must be received at a * 50% after Deductible has been met.

Designated Facility.

Urgent Care Center Services 100% after you pay a $100 Copayment per visit.

50% after Deductible has been met.

100% after you pay a $25 Copayment per visit for Premium Designated PCP. 100% after you pay a $45 Copayment per visit for non-Premium Designated PCP.

Non-Network Benefits are not available.

Vision Examinations Benefits are limited as follows: 1 exam every 2 years 1

This benefit category contains services/devices that may be Essential or non-Essential Health Benefits as defined by the Patient Protection and Affordable Care Act depending upon the service or device delivered. A benefit review will take place once the dollar limit is exceeded. If the service/device is determined to be rehabilitative or habilitative in nature, it is an Essential Health Benefit and will be paid. If the benefit/device is determined to be non-essential, the maximum will have been met and the claim will not be paid.

27

Medical MEDICAL EXCLUSIONS It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

Alternative Treatments Acupressure; aromatherapy; hypnotism; massage therapy; rolfing (holistic tissue massage); art, music, dance, horseback therapy; and other forms of alternative treatment as defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. This exclusion does not apply to Manipulative Treatment and non-manipulative osteopathic care for which Benefits are provided as described in the SPD. Dental Dental care (which includes dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia). This exclusion does not apply to dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Plan as described in the SPD. Dental care that is required to treat the effects of a medical condition, but that is not necessary to directly treat the medical condition, is excluded. Examples include treatment of dental caries resulting from dry mouth after radiation treatment or as a result of medication. Endodontics, periodontal surgery and restorative treatment are excluded. Diagnosis or treatment of or related to the teeth, jawbones or gums. Examples include: extraction (including wisdom teeth), restoration, and replacement of teeth; medical or surgical treatment of dental conditions; and services to improve dental clinical outcomes. This exclusion does not apply to accidental-related dental services for which Benefits are provided as described under Dental Services – Accidental Only in the SPD. Dental implants, bone grafts and other implant-related procedures. This exclusion does not apply to accidentrelated dental services for which Benefits are provided as described under Dental Services – Accident Only in the SPD. Dental braces (orthodontics). Congenital Anomaly such as cleft lip or cleft palate.

Devices, Appliances and Prosthetics Devices used specifically as safety items or to affect performance in sports-related activities. Orthotic appliances that straighten or re-shape a body part as described under Durable Medical Equipment (DME) in the SPD.. Examples include foot orthotics, cranial banding, or any orthotic braces, available over-the-counter. The following items are excluded: blood pressure cuff/monitor; enuresis alarm; non-wearable external defibrillator; trusses; and ultrasonic nebulizers. Devices and computers to assist in communication and speech except for speech generating devices and tracheoesophogeal voice devices for which Benefits are provided as described under Durable Medical Equipment. Oral appliances for snoring. Repair and replacement prosthetic devices when damaged due to misuse, malicious damage or gross neglect. This exclusion does not apply to breast prosthesis, mastectomy bras and lymphedema stockings for which Benefits are provided as described under Reconstructive Procedures in the SPD. Drugs The exclusions listed below apply to the medical portion of the Plan only. Prescription Drug coverage is excluded under the medical plan because it is a separate benefit.

Coverage may be available under the Prescription Drug portion of the Plan. See the SPD for coverage details and exclusions. Prescription drugs for outpatient use that are filled by a prescription order or refill. Self-injectable medications. This exclusion does not apply to medications which, due to their characteristics (as determined by United HealthCare Services, Inc.), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient setting. Non -injectable medications given in a Physician’s office. This exclusion does not apply to non-injectable medications that are required in an Emergency and consumed in the Physician’s office. Over-the-counter drugs and treatments. Growth hormone therapy.

Experimental or Investigational or Unproven Services Experimental or Investigational or Unproven Services, unless the Plan has agreed to cover them as defined in the SPD. This exclusion applies even if Experimental or Investigational Services or Unproven Services, treatments, devices or pharmacological regimens are the only available treatment options for your condition. This exclusion does not apply to Covered Health Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials in the SPD. Foot Care Routine foot care. Examples include the cutting or removal of corns and calluses. This exclusion does not apply to preventive foot care for Covered Persons with diabetes for which Benefits are provided as described under Diabetes Services in the SPD or when needed for severe systemic disease. Cutting or removal of corns and calluses. Nail trimming, cutting, or debriding. Hygienic and preventive maintenance foot care; and other services that are performed when there is not a localized Sickness, Injury or symptom involving the foot. Examples include: cleaning and soaking the feet; applying skin creams in order to maintain skin tone. This exclusion does not apply to preventive foot care for Covered Persons who are at risk of neurological or vascular disease arising from diseases such as diabetes. Treatment of flat feet. Shoes (standard or custom), lifts and wedges; shoe orthotics; shoe inserts and arch supports.

Medical Supplies and Equipment Prescribed or non-prescribed medical supplies and disposable supplies. Examples include: compression stockings, ace bandages, diabetic strips, and syringes; urinary catheters. This exclusion does not apply to:



28

Disposable supplies necessary for the effective use of Durable Medical Equipment for which Benefits are provided as described under Durable Medical Equipment in the SPD.





Diabetic supplies for which Benefits are provided as described under Diabetes Services in the SPD. Ostomy bags and related supplies for which Benefits are provided as described under Ostomy Supplies in the SPD.

Tubings, nasal cannulas, connectors and masks, except when used with Durable Medical Equipment as described under Durable Medical Equipment as described in the SPD. The repair and replacement of Durable Medical Equipment when damaged due to misuse, malicious breakage or gross neglect and deodorants, filters, lubricants, tape, appliance clears, adhesive, adhesive remover or other items that are not specifically identified in the SPD. Mental Health / Substance Use Disorder Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Services or supplies for the diagnosis or treatment of Mental Illness, alcoholism or substance use disorders that, in the reasonable judgment of the Mental Health/Substance Use Disorder Administrator, are any of the following: not consistent with generally accepted standards of medical practice for the treatment of such conditions; not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental; not consistent with the Mental Health/Substance Use Disorder Administrator’s level of care guidelines or best practices as modified from time to time; or not clinically appropriate, and considered ineffective for the patient’s Mental Illness, substance use disorder or condition based on generally accepted standards of medical practice and benchmarks. Mental Health Services as treatments for V-code conditions as listed within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders, sexual dysfunction disorders, feeding disorders, neurological disorders and other disorders with a known physical basis. Treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders, paraphilias (sexual behavior that is considered deviant or abnormal). Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning; tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act. Learning, motor skills and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Mental retardation as a primary diagnosis defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Methadone treatment as maintenance, L.A.A.M. (1-Alpha-AcetylMethadol), Cyclazocine, or their equivalents for drug addiction. Intensive behavioral therapies such as applied behavioral analysis for Autism Spectrum Disorders. Any treatments or other specialized services designed for Autism Spectrum Disorder that are not backed by credible research demonstrating that the services or supplies have a measurable and beneficial health outcome and therefore considered Experimental or Investigational or Unproven Services.

Nutrition Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements, and other nutrition based therapy. Nutritional counseling for either individuals or groups except as defined under Diabetes Services in the SPD. Food of any kind. Foods that are not covered include: enteral feedings and other nutritional and electrolyte formulas, including infant formula and donor breast milk unless they are the only source of nutrition or unless they are specifically created to treat inborn errors of metabolism such as phenylketonuria (PKU) – infant formula available over the counter is always excluded; foods to control weight, treat obesity (including liquid diets), lower cholesterol or control diabetes; oral vitamins and minerals; meals you can order from a menu, for an additional charge, during an Inpatient Stay, and other dietary and electrolyte supplements; and health education classes unless offered by United HealthCare Services, Inc. or its affiliates, including but not limited to asthma, smoking cessation, and weight control classes.

Personal Care, Comfort or Convenience Television; telephone; beauty/barber service; guest service. Supplies, equipment and similar incidental services and supplies for personal comfort. Examples include: air conditioners, air purifiers and filters, dehumidifiers and humidifiers; batteries and battery chargers; breast pumps; car seats; chairs, bath chairs, feeding chairs, toddler chairs, chair lifts, recliners; exercise equipment and treadmills; home modifications to accommodate a health need such as ramps, swimming pools, elevators, handrails and stair glides; hot tubs; Jacuzzis, saunas and whirlpools; ergonomically correct chairs, non-Hospital beds, comfort beds, mattresses; medical alert systems; motorized beds; music devices; personal computers, pillows; power-operated vehicles; radios; saunas; strollers; safety equipment; vehicle modifications such as van lifts; and video players.

Physical Appearance Cosmetic Procedures. See the definition in the SPD. Examples include: pharmacological regimens, nutritional procedures or treatments; Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures); Skin abrasion procedures performed as a treatment for acne; treatment of hair loss; varicose vein treatment of the lower extremities, when it is considered cosmetic; Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple; Treatment for skin wrinkles or any treatment to improve the appearance of the skin; Treatment for spider veins; Hair removal or replacement by any means. Replacement of an existing intact breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Treatment of benign gynecomastia (abnormal breast enlargement in males). Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, health club memberships and programs, spa treatments and diversion or general motivation. Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded, even if for morbid obesity. Wigs regardless of the reason for the hair loss, except for temporary loss of hair resulting from treatment of a malignancy.

Medical Procedures and Treatments Procedure or surgery to remove fatty tissue such as panniculectomy, abdominoplasty, thighplasty, brachioplasty, or mastopexy. Excision or elimination of hanging skin on any part of the body. Examples include plastic surgery procedures called abdominoplasty or abdominal panniculectomy, and brachioplasty. Medical and surgical treatment of excessive sweating (hyperhidrosis). Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea.

Rehabilitation services and Manipulative Treatment to improve general physical condition that are provided to reduce potential risk factors, where significant therapeutic improvement is not expected, including routine, long-term or maintenance/preventive treatment. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cancer, Congenital Anomaly, or autism spectrum disorders. Speech therapy to treat stuttering, stammering or other articulation disorders. Psychosurgery. Sex transformation operations and related services. Physiological modalities and procedures that result in similar or redundant therapeutic effects when performed on the same body region during the same visit or office encounter. Biofeedback. Manipulative treatment to treat a condition unrelated to spinal manipulation and ancillary physiologic treatment rendered to restore/improve motion, reduce pain and improve function, such as asthma or allergies. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the services are considered to be dental in nature, the following services for the diagnosis and treatment of TMJ: surface electromyography; Doppler analysis; vibration analysis; computerized mandibular scan or jaw tracking; craniosacral therapy; orthodontics; occlusal adjustment; dental restorations. Upper and lower jawbone surgery, orthognathic surgery and jaw alignment. This exclusion does not apply to reconstructive jaw surgery required for Covered Persons because of a Congenital Anomaly, acute traumatic Injury, dislocation, tumors, cancer or obstructive sleep apnea. Orthognathic surgery (procedure to correct underbite or overbite) and jaw alignment. Breast reduction except surgery as coverage is required by the Women’s Health and Cancer Right’s Act of 1998 for which Benefits are described under Reconstructive Procedures in the SPD. Non-surgical treatment of obesity even if for morbid obesity. Surgical treatment of obesity unless there is a diagnosis of morbid obesity as described under Obesity Surgery in the SPD. Stand-alone multi-disciplinary smoking cessation programs. These are programs that usually include health care providers specializing in smoking cessation and may include a psychologist, social worker or other licensed or certified professional. The programs usually include intensive psychological support, behavior modification techniques and medications to control cravings. Chelation therapy, except to treat heavy metal poisoning.

Providers Services performed by a provider who is a family member by birth or marriage.

Examples include a spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services performed by a provider with your same legal residence. Services ordered or delivered by a Christian Science practitioner.

Services performed by an unlicensed provider or a provider who is operating outside of the scope of his/her license. Services provided at a free-standing or Hospital based diagnostic facility without an order written by a Physician or other provider. Services which are self-directed to a free-standing or Hospital-based diagnostic facility. Services ordered by a Physician or other provider who is an employee or representative of a free -standing or Hospital-based diagnostic facility, when that Physician or other provider has not been actively involved in your medical care prior to ordering the service, or is not actively involved in your medical care after the service is received. This exclusion does not apply to mammography.

Reproduction Health services and associated expenses for infertility treatments, including assisted reproductive technology, regardless of the reason for the treatment. This exclusion does not apply to services required to treat or correct underlying causes of infertility.

The following infertility treatment-related services: cryo-preservation and other forms of preservation of reproductive materials, long-term storage of reproductive materials such as sperm, eggs, embryos, ovarian tissue, and testicular tissue, donor services.

Surrogate parenting, donor eggs, donor sperm and host uterus. Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue and ovarian tissue. The reversal of voluntary sterilization. Health services and associated expenses for elective surgical, non-surgical, or drug-induced Pregnancy termination. This exclusion does not apply to treatment of a molar Pregnancy, ectopic Pregnancy, or missed abortion (commonly known as a miscarriage). Services provided by a doula (labor aide); and parenting, prenatal or birthing classes. Artificial reproduction treatments done for genetic or eugenic.

Travel Health services provided in a foreign country, unless required as Emergency Health Services.

Travel or transportation expenses, even if ordered by a Physician, except as identified under Travel and Lodging in the SPD. Additional travel expenses related to Covered Health Services received from a Designated Facility or Designated Physician may be reimbursed at the Plan’s discretion. This exclusion does not apply to ambulance transportation for which Benefits are provided as described in the SPD. Types of Care Multi-disciplinary pain management programs provided on an inpatient basis for acute pain or for exacerbation of chronic pain. Custodial care; domiciliary care. Respite care. This exclusion does not apply to respite care that is part of an integrated hospice care program of services provided to a terminally ill person by a licensed hospice care agency for which Benefits are described under Hospice Care in the SPD. Rest cures; services of personal care attendants. Work hardening (individualized treatment programs designed to return a person to work or to prepare a person for specific work).

Vision and Hearing Purchase cost and associated fitting charge for eye glasses and contact lenses. Implantable lenses used only to correct a refractive error (such as Intacs corneal implants)., Bone Anchor Hearing Aids (BAHA) and all other hearing assistive devices. Bone anchored hearing aids except when either of the following applies: for Covered Persons with craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid or for Covered Persons with hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid. Eye exercise or vision therapy. Surgery and other related treatment that is intended to correct nearsightedness, farsightedness, presbyopia and astigmatism including, but not limited to, procedures such as laser and other refractive eye surgery and radial keratotomy.

All Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service – see the definition of Covered Health Services in the Glossary in the SPD. Covered Health Services are those health services including services, supplies or Prescription Drugs, which the Claims Administrator determines to be all of the following: Medically Necessary; described as a Covered Health Service in the SPD; and not otherwise excluded in the SPD. Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments when: required solely for purposes of education, school, sports or camp, travel, career or employment, insurance, marriage or adoption; or as a result of incarceration; related to judicial or administrative proceedings or orders; conducted for purposes of medical research; required to obtain or maintain a license of any type. This exclusion does not apply to Covered Health Services provided during a clinical trial for which Benefits are provided as described in the SPD. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. This exclusion does not apply to Covered Persons who are civilians injured or otherwise affected by war, any act of war or terrorism in a non-war zone. Health services received after the date your coverage under the Plan ends. This applies to all health services, even if the health service is required to treat a medical condition that arose before the date your coverage under the Plan ended. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Plan. Charges that exceed Eligible Expenses or any specified limitation in the SPD. Foreign language and sign language services. Health services related to a nonCovered Health Service: When a service is not a Covered Health Service, all services related to that non-Covered Health Service are also excluded. This exclusion does not apply to services the Plan would otherwise determine to be Covered Health Services if they are to treat complications that arise from the non-Covered Health Service. For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that is superimposed on an existing disease and that affects or modifies the prognosis of the original disease or condition. Examples of a "complication" are bleeding or infections, following a Cosmetic Procedure, that require hospitalization. Health services when a provider waives the Copay, Annual Deductible or Coinsurance amounts. Autopsies and other coroner services and transportation services for a corpse. Charges for: missed appointments; room or facility reservations; completion of claim forms; or record processing. Charges prohibited by federal anti-kickback or self-referral status. Diagnostic tests that are: delivered in other than a Physician’s office or health care facility; and selfadministered home diagnostic tests, including but not limited to HIV and pregnancy tests.

Vision therapy when rendered in connection with behavioral health disorders, including but not limited to: learning and reading disabilities; attention deficit/hyperactively disorder; TBI; or dyslexia.

Services Provided under Another Plan Health services for which other coverage is available under another plan, except for Eligible Expenses payable as described in the SPD. Examples include coverage required by workers’ compensation, no-fault auto insurance, or similar legislation. If coverage under workers’ compensation, no-fault automobile coverage or similar legislation is optional for you because you could elect it, or could have it elected for you. Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty.

Transplants Health services for organ and tissue transplants, except as identified under Transplantation Services in the SPD unless United HealthCare Services, Inc. determines the transplant to be appropriate according to United HealthCare Services, Inc.’s transplant guidelines. Mechanical or animal organ transplants, except services related to the implant or removal of a circulatory assist device (a device that supports the heart while the patient waits for a suitable donor heart to become available); and donor costs for organ or tissue transplantation to another person (these contest may be payable through the recipient’s benefit plan).

29

VOYA YOUR BENEFITS PACKAGE

Hospital Indemnity

About this Benefit Hospital Indemnity insurance is designed to supplement your medical coverage, easing the financial impacts by helping cover additional expenses associated with a hospital stay. It provides a benefit payable directly to you for hospitalization and other benefits as listed in the policy.

30

DID YOU KNOW? The median hospital costs per stay have steadily grown to over $10,000.

$8,800

$9,600

$10,400

2003

2008

2012

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Hospital Indemnity Consider the following:

 The average cost per day for an hospital stay in the United States is more than $4,000.1  About 1 in 16 U.S. residents age 18 to 44 required one or more hospital stays in 2012. For ages 45 to 64, it was about 1 in 13.2 1

“As Hospital Prices Soar, a Stitch Tops $500.” New York Times, Dec. 2, 2013.

2 “Health, United States.” National Center for Health Statistics, Centers for Disease Control and Prevention, 2013.

The costs of a hospital stay aren’t confined to hospital bills, either. There’s transportation, parking, food and drink for visitors, rehabilitation expenses, and potentially lost work time. Compass Hospital Confinement Indemnity Insurance can help reduce your financial stress during recovery.

About Compass Hospital Confinement Indemnity Insurance Compass Hospital Confinement Indemnity Insurance is a limited benefit policy. This is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

Hospital confinement indemnity insurance pays lump sum benefit amounts based on the number of days spent in a hospital*, critical care unit, or rehabilitation facility. You can use this benefit for any purpose you like, for example: to help pay for expenses not covered by your medical plan, lost wages, child care, travel, home health care costs, or any of your regular household expenses. *A hospital does not include an institution or part of an institution used as: a hospice unit; a convalescent home; a rest or nursing facility; a free-standing surgical center; 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.

If you are an employee who works at least 20 hours a week you qualify for this insurance. There are no medical questions you need to answer or medical tests you need to take to get coverage.

This policy is portable – which means that if you leave your employer, you can maintain your coverage. If you choose to keep your coverage, you will be billed directly.

Your Compass Hospital Confinement Indemnity Insurance Plan The plan pays a daily benefit based on the coverage level you select. See accompanying rate sheet for available coverage levels.

You will be asked for supporting documentation in order for a benefit to be paid. Please see the complete certificate and any applicable rider(s) for details. Please refer to the back pages of this document for a list of the exclusions and limitations that apply to this coverage.

Spouse Hospital Confinement Indemnity Insurance Rider You may elect hospital confinement indemnity insurance coverage for your spouse*, through age 69. The spouse/ domestic partner daily benefit may or may not match the employee benefit amount, so see your available election choices on the accompanying rate sheet or review the complete certificate for details. You must have coverage for yourself in order to select this rider. Please refer to the back pages of this document for a list of the exclusions and limitations that apply to this coverage. *Definition of spouse may vary by state

Children’s Hospital Confinement Indemnity Insurance Rider You may elect hospital confinement indemnity insurance coverage for your child or children, up to age 26. One rider covers all of your eligible children. The child daily benefit amount may be different from what is available to employees and spouses, so see your election choices on the accompanying rate sheet or the complete certificate for details. You must have coverage for yourself in order to select this rider. Please refer to the back pages of this document for a list of the exclusions and limitations that apply to this coverage.

This is an optional benefit that you can purchase. Premium payments will be made through automatic deduction from your paycheck. This brochure will describe the coverage and options available to you.

31

Hospital Indemnity Exclusions and Limitations* Benefits are not payable for any loss caused in whole or directly by any of the following: Exclusions and Limitations

Applies To

Participation or attempt to participate in a felony or illegal activity.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Operation of a motorized vehicle while intoxicated. Intoxication means the covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

War or any act of war, whether declared or undeclared (excluding acts of terrorism).

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Elective surgery, except when required for appropriate care as a result of the covered person’s injury or sickness.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Practicing for, or participating in, any semiprofessional or professional competitive athletic contests for which any type of compensation or remuneration is received.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Work for pay, profit or gain, if the employer elects to exclude work-related sicknesses or accidents under the policy.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Any sickness or declining process caused by a sickness.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

There is a 30-day benefit waiting period.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

For the first 12 months following the covered person’s coverage effective date (including the effective dates of any increases to coverage), we will not pay benefits for any Confinement resulting from a Pre-Existing Condition.

Following the satisfaction of the Pre-Existing Condition limitation time period, benefits for a Pre-Existing Condition are the same as benefits for any eligible Confinement.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

Benefits reduce 50% on the policy anniversary following the insured's 70th birthday; however, premiums do not reduce as a result of this benefit change.

Certificate, Spouse Hospital Confinement Indemnity Rider, and Children’s Hospital Confinement Indemnity Rider.

*The exclusions and limitations may vary by state. Consult your certificate of insurance and riders for exact language.

32

Hospital Indemnity

Spouse Daily Benefit (Spouse Rates are based on the age of the spouse) Monthly Rates Uni-Tobacco

Employee Daily Benefit Level(s) Monthly Rates Uni-Tobacco Attained Age

$100

$200

$300

Attained Age

$100

$200

$300

Under 20

$5.73

$11.46

$17.19

Under 20

$6.30

$12.60

$18.90

20-24

$5.73

$11.46

$17.19

20-24

$6.30

$12.60

$18.90

25-29

$6.38

$12.76

$19.14

25-29

$7.02

$14.04

$21.06

30-34

$6.76

$13.52

$20.28

30-34

$7.44

$14.88

$22.32

35-39

$6.51

$13.02

$19.53

35-39

$7.16

$14.32

$21.48

40-44

$6.79

$13.58

$20.37

40-44

$7.47

$14.94

$22.41

45-49

$8.02

$16.04

$24.06

45-49

$8.76

$17.52

$26.28

50-54

$9.86

$19.72

$29.58

50-54

$10.78

$21.56

$32.34

55-59

$12.36

$24.72

$37.08

55-59

$13.70

$27.40

$41.10

60-64

$16.20

$32.40

$48.60

60-64

$17.96

$35.92

$53.88

65-69

$20.96

$41.92

$62.88

65-69

$23.24

$46.48

$69.72

70+

$27.04

$54.08

$81.12

70+

N/A

N/A

N/A

Children Daily Benefits Monthly Rates Coverage Amount

Rate

$100

$5.34

$200

$10.68

$300

$16.02

Rates shown are for the Daily Benefit Amount. The Hospital Confinement Benefit Amount is one times the Daily Benefit Amount per covered day. The Rehabilitation Facility Confinement Benefit is one-half of the Daily Benefit Amount per covered day. The Critical Care Unit Confinement Benefit Amount is two times the Daily Benefit Amount per covered day.

33

VOYA

Critical Illness

YOUR BENEFITS PACKAGE

About this Benefit Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.

DID YOU KNOW?

$16,500 Is the aggregate cost of a hospital stay for a heart attack.

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Critical Illness

In the United States, someone has a heart attack, on average, every 34 seconds.1 For strokes, the average is one every 40 seconds.2

   

“Heart Disease Fact Sheet.” Centers for Disease Control and Prevention, 2010.

2 “Impact of Stroke.” American Heart Association, 2011.

  

Heart Attack Stroke End Stage Renal (Kidney) Failure Coronary Artery Bypass (25% of the maximum critical illness benefit) Coma Major Organ Failure Permanent Paralysis

   

Deafness Blindness Benign Brain Tumor Occupational HIV

 

Cancer Carcinoma In Situ (25% of the maximum critical illness benefit) Skin Cancer (10% of the maximum critical illness benefit)

Consider the following:   1

These and other critical illnesses can derail your life.

They can keep you from working. They can make it difficult to do the simple things that you take for granted every day. And while no insurance product could ever erase the impact of a critical illness, Compass Critical Illness Insurance can help reduce your stress during recovery.

About Compass Critical Illness Insurance Compass Critical Illness Insurance is a limited benefit policy. This is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. Critical illness insurance pays a one-time, lump sum benefit amount upon the diagnosis of a covered disease or illness. You can use this money for any purpose you like, for example: to help pay for expenses not covered by your medical plan, lost wages, child care, travel, home health care costs, or any of your regular household expenses.

If you are an employee who works at least 20 hours a week, you qualify for this insurance. There are no medical questions you need to answer or medical tests you need to take to get coverage.

This is an optional benefit that you can purchase.

Premium payments will be made through automatic deduction from your paycheck. This brochure will describe the coverage and options available to you.

This policy is portable – which means that if you leave your employer, you can maintain your coverage. If you choose to keep your coverage, you will be billed directly.

Your Compass Critical Illness Plan The plan pays the maximum critical illness benefit available for a covered condition or specified disease, unless otherwise indicated by a percentage.



You will be asked for supporting documentation in order for a benefit to be paid. Please see the complete certificate and any applicable rider(s) for details.

Once the maximum benefit has been paid on an illness, coverage will terminate for that covered person for all other conditions or illnesses in the same box above.

Any partial benefits paid will not reduce the available maximum benefit amount for the conditions or illnesses in that same colored box. Provided premiums are paid, coverage would continue for other covered family members.

Wellness Benefit Rider The covered employee will receive a single standard annual benefit of $100 for each covered employee and spouse who completes a health screening test. (The standard child benefit is 50% of the employee benefit amount, with a maximum of $100 in child benefits payable per calendar year.)

Restoration of Benefits Rider The insured person’s coverage will remain in effect after suffering a critical illness, and will pay an additional benefit if the insured person experiences a second and different covered illness following a period of 12 consecutive months during which both of the following are true: 

The insured has had no occurrence of any covered critical illness

35

Critical Illness 

The insured has been free of the covered condition(s) for which benefits were previously paid.





This rider doesn’t apply to cancer coverage.

Recurrence Rider The insured person can receive a benefit for the same critical illness twice, following a period of 12 consecutive months during which both of the following are true:  

The insured has had no occurrence of any covered critical illness The insured has been free of the covered condition(s) for which benefits were previously paid.

This rider doesn’t apply to cancer coverage.

Spouse Critical Illness Rider You may elect critical illness insurance coverage for your spouse*, through age 69. The spouse maximum critical illness benefit may or may not match the employee benefit amount, so see your available election choices or review the complete certificate for details. You must have coverage for yourself in order to select this rider. *Definition of spouse may vary by state.



War or any act of war, whether declared or undeclared (excluding acts of terrorism).

Loss sustained while on active duty as a member of the armed forces of any nation. However, we will refund, upon written notice of such service, any premium that has been accepted for any period not covered as a result of this exclusion.

Alcoholism, drug abuse or misuse of alcohol or taking of drugs, other than under the direction of a Doctor.

Benefit Waiting Period There is a 30-day benefit waiting period.

Pre-Existing Condition Limitation Pre-existing condition means a sickness, injury or physical condition which, within the 12 month period prior to your coverage effective date, resulted in you receiving medical treatment, consultation, care or services (including diagnostic measures).

For the first 12 months following your coverage effective date (including the effective dates of any increases to coverage), we will not pay benefits for any condition or illness resulting from a pre-existing condition. Following the satisfaction of the pre-existing condition limitation time period, benefits for a pre-existing condition are the same as benefits for any eligible condition.

Children’s Critical Illness Rider You may elect critical illness insurance coverage for your child or children, up to age 26. One rider covers all of your eligible children. The coverage level amounts may be different from what is available to employees and spouses, so see your election choices or the complete certificate for details. You must have coverage for yourself in order to select this rider.

Exclusions and Limitations* Benefits are not payable for any critical illness caused in whole or directly by any of the following:  

36

Participation or attempt to participate in a felony or illegal activity.

Suicide, attempted suicide or any intentionally selfinflicted injury, while sane or insane.

Coverage Reduction Benefits reduce 50% for the employee and spouse (if applicable) on the policy anniversary following the insured's 70th birthday; however, premiums do not reduce as a result of this benefit change.

Children’s Critical Illness Rider Limitations and Exclusions The exclusions are the same as the above, PLUS no benefit is payable for the covered person’s children for Carcinoma in Situ, Coronary Artery Bypass or Skin Cancer. *The exclusions and limitations on this page may vary by state.

Critical Illness Employee Coverage Monthly Rates (Includes Wellness Benefit Rider) Non-Tobacco

Tobacco

Attained Age

$5,000

$10,000

$15,000

$20,000

Attained Age

$5,000

$10,000

$15,000

$20,000

Under 20

$2.15

$4.30

$6.45

$8.60

Under 20

$3.70

$7.40

$11.10

$14.80

20-24

$2.15

$4.30

$6.45

$8.60

20-24

$3.70

$7.40

$11.10

$14.80

25-29

$2.25

$4.50

$6.75

$9.00

25-29

$3.90

$7.80

$11.70

$15.60

30-34

$2.55

$5.10

$7.65

$10.20

30-34

$4.60

$9.20

$13.80

$18.40

35-39

$3.25

$6.50

$9.75

$13.00

35-39

$5.95

$11.90

$17.85

$23.80

40-44

$4.60

$9.20

$13.80

$18.40

40-44

$8.65

$17.30

$25.95

$34.60

45-49

$6.75

$13.50

$20.25

$27.00

45-49

$12.95

$25.90

$38.85

$51.80

50-54

$9.55

$19.10

$28.65

$38.20

50-54

$18.55

$37.10

$55.65

$74.20

55-59

$13.05

$26.10

$39.15

$52.20

55-59

$25.25

$50.50

$75.75

$101.00

60-64

$18.25

$36.50

$54.75

$73.00

60-64

$35.35

$70.70

$106.05

$141.40

65-69

$26.90

$53.80

$80.70

$107.60

65-69

$52.10

$104.20

$156.30

$208.40

70+

$37.55

$75.10

$112.65

$150.20

70+

$72.10

$144.20

$216.30

$288.40

Spouse Coverage* Monthly Rates (Includes Wellness Benefit Rider) Non-Tobacco

Children Coverage Monthly Rates (Includes Wellness Benefit Rider)

Tobacco $10,000

Coverage Amount

Rate

$5.40

$10.80

$1,000

$0.92

20-24

$5.40

$10.80

$2,500

$2.30

$6.80

25-29

$5.90

$11.80

$5,000

$4.60

$3.80

$7.60

30-34

$6.65

$13.30

$10,000

$9.20

35-39

$4.55

$9.10

35-39

$8.15

$16.30

40-44

$6.30

$12.60

40-44

$11.45

$22.90

45-49

$9.35

$18.70

45-49

$17.40

$34.80

50-54

$14.50

$29.00

50-54

$27.65

$55.30

55-59

$21.60

$43.20

55-59

$41.85

$83.70

60-64

$29.10

$58.20

60-64

$56.75

$113.50

65-69

$37.30

$74.60

65-69

$72.70

$145.40

70+

$50.15

$100.30

70+

$96.85

$193.70

Attained Age

$10,000

Attained Age

$5,000

$5,000

Under 20

$3.15

$6.30

Under 20

20-24

$3.15

$6.30

25-29

$3.40

30-34

*Spouse rates are based on the age of the employee.

37

VOYA YOUR BENEFITS PACKAGE

Accident

About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

DID YOU KNOW?

2/3 of disabling injuries suffered by American workers are not work related.

American workers 36% ofreport they always or

usually live paycheck to paycheck.

38

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Accident Consider the following:  

In the United States, there were nearly 30 million unintentional non-fatal injuries in 2010 alone.1 Unintentional injuries requiring hospitalization cost nearly $22,000 on average.1

1

WISQARS Nonfatal Injury Reports, Centers for Disease Control and Prevention, based on 2010 data You can’t prepare for an accident – but you can prepare for its aftermath. Compass Accident Insurance, offered to you by Voya Employee Benefits, can help you chart a course to a less stressful recovery.

About Compass Accident Insurance Compass Accident Insurance is a limited benefit policy. This is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. Accident insurance pays you a specified amount for specific injuries resulting from a covered accident. You can use this money in any way you like, for example: deductibles, child care, housecleaning, groceries, utilities – any purpose that can help you meet your personal, financial, or household needs.

If you are an employee who works at least 20 hours per week, you qualify for this insurance. There are no medical questions you need to answer or medical tests you need to take to get coverage.

This is an optional benefit that you can purchase. Premium payments will be made through automatic deduction from your paycheck. This brochure will describe the coverage and options available to you.

This coverage is portable – which means that if you leave your employer, you can maintain your coverage. If you choose to keep your coverage, you will be billed directly.

Your Compass Accident Plan – Off Job Coverage This is a brief outline of available benefits. Each benefit is subject to terms and conditions that may reduce the final amount paid, depending on the circumstances of your accident and the care you receive. Ask your benefits manager if you have questions about these terms and conditions.

Benefits are for each covered person for each covered accident unless otherwise indicated. The services listed below must be related to a covered accident. Benefits may vary by state. Please review your certificate of coverage for exact language.

Accident Hospital Care Surgery Open abdominal, thoracic Surgery Exploratory or without repair Blood, Plasma, Platelets Hospital Admission Hospital Confinement Per day up to 365 Coma Duration of 14 or more days Transportation Per trip up to 3 per accident Lodging Per day up to 30 days

$800 $80 $240 $800 $200 $4,000 $240 $80

Follow-up Care Medical Equipment Physical Therapy Per treatment up to 6 Prosthetic Device One Prosthetic Device 2 or more

$40 $20 $400 $800

Common Injuries Burns 2nd degree—at least 36% of the $600 body Burns 3rd degree—at least 9 but less $1,200 than 35 square inches of the body Burns 3rd degree—35 or more square $8,000 inches of the body Skin Grafts 25% of burn benefit Emergency Dental Work Crown: $120 while Hospital Confined Extraction: $40 Eye Injury $40 Removal of foreign object Eye Injury $160 Surgery Torn Knee Cartilage Surgery with no repair or if $80 cartilage is shaved Torn Knee Cartilage $400 Surgical repair Laceration1 $20 Treated, no sutures 1 Laceration $40 Sutures, up to 2” Laceration1 $160 Sutures, 2” to 6”

39

Accident Common Injuries (cont.)

Laceration1 Sutures, over 6” Ruptured Disk Surgical repair Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff 2 or more, surgical repair Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with no repair Concussion Paralysis Quadriplegia Paralysis Paraplegia

Common Injuries Fractures (cont.) $320 $320 $320 $480 $80 $80 $8,000 $4,000

Common Injuries Dislocations

Hip Joint Knee Ankle or Foot Bone(s) Other than toes Shoulder Elbow Wrist Finger/Toe Hand Bone(s) Other than fingers Lower Jaw Collarbone Partial Dislocations

Closed Reduction/ Open Reduction2 $1,600/ $3,200 $800/ $1,600 $640/ $1,280 $240/ $480 $240/ $480 $240/ $480 $80/ $160 $240/ $480 $240/ $480 $240/ $480 25% of the closed reduction amount

Common Injuries Fractures

Hip

1

Closed Reduction/ Open Reduction3 $1,200/ $2,400

Closed Reduction/ Open Reduction3 $640/ Leg $1,280 $240/ Ankle $480 $240/ Kneecap $480 Foot $240/ (excluding toes, heel) $480 $280/ Upper Arm $560 Forearm, Hand, Wrist $240/ (except fingers) $480 $40/ Finger, Toe $80 $640/ Vertebral Body $1,280 $240/ Vertebral Processes $480 Pelvis $640/ (except Coccyx) $1,280 $160/ Coccyx $320 Bones of Face $280/ (except nose) $560 $80/ Nose $160 $280/ Upper Jaw $560 $240/ Lower Jaw $480 $240/ Collarbone $480 $200/ Rib or Ribs $400 Skull—simple (except bones of $800/ face) $1,600 Skull—depressed (except bones of $2,000/ face) $4,000 $240/ Sternum $480 $240/ Shoulder Blade $480 25% of the closed Chip Fractures reduction amount

Laceration benefits are a total of all lacerations per accident.

Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a completely separated joint.

3 Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical.

2

40

Accident Spouse Accident Rider



You may elect accident insurance coverage for your spouse*, through age 69. See the complete certificate and rider for details. You must have coverage for yourself in order to select this rider.



*Definition of spouse may vary by state.

Practicing for, or participating in, any semiprofessional or professional competitive athletic contests for which any type of compensation or remuneration is received.

Any sickness or declining process caused by a sickness.

*Exclusions and limitations may vary by state. Consult your certificate of insurance for exact language.

Monthly Rates

Children’s Accident Rider You may elect accident insurance coverage for your child or children, up to age 26. One rider covers all eligible children.

See the complete certificate and rider for details. You must have coverage for yourself in order to select this rider.

Exclusions and Limitations* Exclusions in the Certificate, Spouse Accident Rider, Children’s Accident Rider and Accidental Death & Dismemberment Rider: Benefits are not payable for any loss caused in whole or directly by any of the following:  

  

  



Tier

Rate

Employee Only

$2.85

Employee + Spouse

$5.00

Employee + Child(ren)

$6.41

Family Coverage

$8.56

Participation or attempt to participate in a felony or illegal activity.

An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred.

Suicide, attempted suicide or any intentionally selfinflicted injury, while sane or insane.

War or any act of war, whether declared or undeclared (excluding acts of terrorism).

Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.

Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.

Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded.

Engaging in hang-gliding, bungee jumping, parachuting, sailgliding, parasailing, parakiting, kitesurfing or any similar activities.

41

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.

42

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Dental PPO - High Option Monthly PPO Premiums Tier

Rate

EE Only

$35.78

EE + Spouse

$69.85

EE + Child(ren)

$85.42

Family Coverage

$112.96

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features.

When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits

Cigna Dental PPO In-Network Total Cigna DPPO

Out-of-Network

Calendar Year Maximum (Class I, II, III, V and IX expenses)

Year 1: $1,000 Year 2: $1,150# Year 3: $1,300+ Year 4: $1,450^

Year 1: $1,000 Year 2: $1,150# Year 3: $1,300+ Year 4: $1,450^

Annual Deductible Individual Family

$50 per person $150 per family

$50 per person $150 per family

Network

Reimbursement Levels** Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Class II - Basic Restorative Care Fillings Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Brush Biopsies Oral Surgery – Simple Extractions Class III - Major Restorative Care Root Canal Therapy/Endodontics Osseous Surgery Surgical Extractions of Impacted Teeth Oral Surgery – all except simple extractions Crowns Dentures Denture Repairs Denture Relines, Rebases and Adjustments Bridges Inlays/Onlays Prosthesis Over Implant Periodontal Scaling and Root Planing Anesthetics Repairs to Bridges, Crowns and Inlays Class IV - Orthodontia Lifetime Maximum Class V - TMJ Class IX - Implants

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances Plan Pays You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50%*

50%*

50%*

50% $1,000 Dependent children to age 19 50%*

50%

50%

50%*

50% $1,000 Dependent children to age 19 50%*

50%*

50%*

50%*

50%*

50%* 43

Dental PPO - Low Option Monthly PPO Premiums Tier

Rate

EE Only

$28.44

EE + Spouse

$55.53

EE + Child(ren)

$67.93

Family Coverage

$89.96

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features.

When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits

Cigna Dental PPO In-Network Total Cigna DPPO

Out-of-Network

Calendar Year Maximum (Class I, II, III, V and IX expenses)

Year 1: $1,000 Year 2: $1,150# Year 3: $1,300+ Year 4: $1,450^

Year 1: $1,000 Year 2: $1,150# Year 3: $1,300+ Year 4: $1,450^

Annual Deductible Individual Family

$50 per person $150 per family

$50 per person $150 per family

Network

Reimbursement Levels**

90th percentile of Reasonable and Customary Allowances Plan Pays You Pay

Plan Pays

You Pay

90%

10%

90%

10%

60%*

40%*

60%*

40%*

50%*

50%*

50%*

50%*

Not covered

100% of your dentist’s usual fees

Not covered

100% of your dentist’s usual fees

Class V - TMJ

50%*

50%*

50%*

50%*

Class IX - Implants

50%*

50%*

50%*

50%*

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Class II - Basic Restorative Care Fillings Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Oral Surgery – Simple Extractions Brush Biopsies Class III - Major Restorative Care Root Canal Therapy/Endodontics Osseous Surgery Surgical Extractions of Impacted Teeth Oral Surgery – all except simple extractions Crowns Dentures Denture Repairs Denture Relines, Rebases and Adjustments Bridges Inlays/Onlays Prosthesis Over Implant Periodontal Scaling and Root Planing Anesthetics Repairs to Bridges, Crowns and Inlays Class IV - Orthodontia

44

Based on Reduced Contracted Fees

Dental PPO - High and Low Option 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 Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14.

Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions     

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

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

In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

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 the Contracted Fee Schedule but the dentist may balance bill up to their usual fees. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1,2 and 3

45

Dental DHMO 

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services.



This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday.



Procedures not listed on the full Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees.



The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment.



Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable.



This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.



Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/ certificate of coverage and/or group contract.



All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.



The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. The language in italics is intended to clarify the member’s benefit.

After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials. Multiple ways to locate a *DHMO Network General Dentist:  Online provider directory at www.Cigna.com  Online provider directory on www.myCigna.com  Call the number located on your ID card to: - Use the Dental Office Locator via Speech Recognition - Speak to a Customer Service Representative For full Patient Charge Schedule, go to www.mybenefitshub.com/kellerisd Code

Procedure Description

Member Pays

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145). The frequency of certain covered services, like cleanings, is limited. If your network general dentist certifies to Cigna Dental that, due to medical necessity, you require certain covered services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant covered services are identified with a Δ.

46

Code

Procedure Description

Member Pays

Diagnostic/preventive (cont.)

D0145

Oral evaluation for a patient under 3 years of age and counseling with primary caregiver

$0.00

D0150

Comprehensive oral evaluation – New or established patient

$0.00

D0210

X-rays intraoral – Complete series of radiographic images (Limit 1 every 3 years) Δ

$0.00

D0240

X-rays intraoral – Occlusal radiographic image

$0.00

D9310

Consultation (Diagnostic service provided by dentist or physician other than requesting dentist or physician)

$10.00

D9430

Office visit for observation (During regularly scheduled hours) – No other services performed

$5.00

D0270

X-rays (Bitewing) – Single radiographic image

$0.00

D0120

Periodic oral evaluation – Established patient

$0.00

D0330

X-rays (Panoramic radiographic image) – (Limit 1 every 3 years) Δ

$0.00

D0140

Limited oral evaluation – Problem focused

$0.00

D0431

Oral cancer screening using a special light source

$50.00

Dental DHMO Code

Procedure Description

Member Pays

Diagnostic/preventive (cont.)

Code

Procedure Description

Member Pays

Periodontics (cont.)

D1110

Prophylaxis (Cleaning) – Adult (Limit 2 per calendar year) Δ

$0.00

D1120

Prophylaxis (Cleaning) – Child (Limit 2 per calendar year) Δ

$0.00

D1206

Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year. Δ

$0.00

D1351

Sealant – Per tooth

$10.00

D4341

Periodontal scaling and root planing – 4 or more teeth per quadrant (Limit 4 quadrants per consecutive 12 months) Δ

$40.00

D4342

Periodontal scaling and root planing – 1 to 3 teeth per quadrant (Limit 4 quadrants per consecutive 12 months) Δ

$30.00

D4910

Periodontal maintenance (Limit 4 per calendar year) (Only covered after active periodontal therapy) Δ

$30.00

Additional periodontal maintenance procedures (Beyond 4 per calendar year)

$55.00

Periodontal charting for planning treatment of periodontal disease

$0.00

Periodontal hygiene instruction

$0.00

Restorative (Fillings, including polishing) D2140

Amalgam – 1 surface, primary or permanent

$0.00

D2330

Resin-based composite – 1 surface, anterior

$0.00

D2390

Resin-based composite crown, anterior

$35.00

Crown and bridge – All charges for crowns and bridges (Fixed partial dentures) are per unit (Each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years.

For single crowns, retainer (“Abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy.

You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration.  No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys  No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth)  Porcelain/ceramic substrate crowns on molar teeth are not covered D2740

Crown – Porcelain/ceramic substrate

$225.00

D2792

Crown – Full cast noble metal

$185.00

D2722

Crown – Resin with noble metal

$185.00

D2950

Core buildup – Including any pins

$50.00

Prosthetics (Removable tooth replacement – Dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $200.00 per denture.

D5110

Full upper denture

$150.00

D5120

Full lower denture

$150.00

D5211

Upper partial denture – Resin base (Including clasps, rests and teeth)

$150.00

D5212

Lower partial denture – Resin base (Including clasps, rests and teeth)

$150.00

Oral surgery (Includes routine postoperative treatment) surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists.

D7111

Extraction of coronal remnants – Deciduous tooth

$5.00

D7140

Extraction, erupted tooth or exposed root – Elevation and/or forceps removal

$5.00

D7220

Removal of impacted tooth – Soft tissue

$50.00

D7240

Removal of impacted tooth – Completely bony

$90.00

Endodontics (Root canal treatment, excluding final restorations) D3310

Anterior root canal – Permanent tooth (Excluding final restoration)

$80.00

D3330

Molar root canal – Permanent tooth (Excluding final restoration)

$250.00

Periodontics (Treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the Patient Charge Schedule. If your network dentist certifies to Cigna Dental that, due to medical necessity, you require certain covered services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant covered services are identified with a Δ.

D4211

Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant

$80.00

D4240

Gingival flap (Including root planing) – 4 or more teeth per quadrant

$150.00

Orthodontics (Tooth movement) orthodontic treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.)

D8670

Periodic orthodontic treatment visit – As part of contract Children – Up to 19th birthday: 24-month treatment fee Charge per month for 24 months

$1,344.00 $56.00

Adults: 24-month treatment fee Charge per month for 24 months

$1,944.00 $81.00

47

SUPERIOR 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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Vision Benefits

In-Network

Out-of-Network

Covered in full

Up to $42 retail

Exam (optometrist) Frames

Covered in full $130 retail allowance

Up to $37 retail Up to $68 retail

Contact Lens Fitting (standard)

Covered in full

Not Covered

Contact Lens Fitting (specialty₂)

$50 retail allowance

Not Covered

Contact Lenses4

$130 retail allowance Up to $100 retail

Exam (ophthalmologist)

Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive lens upgrade

Covered in full Covered in full Covered in full

Up to $32 retail Up to $46 retail Up to $61 retail

See description3

Up to $61 retail

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

Monthly Premiums Emp. only

$8.10

Emp. + 1 dependent

$15.70

Emp. + family

$23.08

Co-Pays Exam

$10

Materials₁ Contact Lens Fitting (standard & specialty)

$0 $25

Services/Frequency Exam

1 per calendar year

Frame

1 per calendar year

Contact Lens Fitting

1 per calendar year

Lenses

1 pair per calendar year

Contact Lenses

1 allowance per calendar year

₁ Materials co-pay applies to lenses & frames only, not contact lenses. ₂The specialty contact lens fitting is for new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. ₃Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary.

Discounts on Covered Materials5 Frames: Lens options: Progressives:

20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options

The following options have out-of-pocket maximums on standard (not premium, brand, or progressive) plastic lenses.

5Discounts

and maximums may vary by lens type. Please check with your

provider.

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal Scratch coat $13 $13 Ultraviolet coat $15 $15 Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50 Polycarbonate $40 20% off retail High index 1.6 $55 20% off retail Photochromics $80 20% off retail

Discounts on Non-Covered Exam and Materials5 Exams, frames, and prescription lenses: Lens options, contacts, other prescription materials: Disposable contact lenses: 5Discounts

30% off retail 20% off retail 10% off retail

and maximums may vary by lens type. Please check with your

provider.

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 15%-50%, and are the best possible discounts available to Superior Vision.

The Plan discount features are not insurance. All allowances are retail; member is responsible for any amount over the allowance, minus available discounts.

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.

49

QCD

Discount Dental & Vision

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.

50

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.

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Discount Dental & Vision The QCD Philosophy QCD believes that you should pay the lowest monthly cost possible for comprehensive dental and vision benefit coverage for your family. The member benefits from significant cost savings when and if services are used.

Monthly Cost MONTHLY Employee Only

No Charge

Employee + Child(ren)

$10.00

Employee + Family

$14.00

Why Select QCD? When selecting dental benefits, QCD makes good financial sense. QCD allows you to allocate more of your benefit expenditures to your rising medical costs. A single dental procedure (Root Canal and Crown) could cost you as much as $2000 with no coverage. The QCD program will allow you to save up to 60% on the total cost – that could be as much as $1200 in savings and enough to fund your family’s monthly dental and vision benefit costs for several years.

The Best Dental & Vision Benefit Value QCD offers over 3,000 highly qualified dental professionals.

To locate a dentist in your area, visit www.qcdofamerica.com and type in your zip code The average appointment availability is less than two weeks QCD Client Services Team is ready and willing to assist you in all your needs such as:  Benefit Questions  Treatment plans  Coverage Levels QCD Membership Services Team is available for all general questions including:  Finding a Dentist  Setting Appointments  Vision Benefits If your dentist is not affiliated with QCD, please fill out the Dentist Referral Form and turn it into your HR Director or you can fax it to our Provider Relations Department at 972726-0448.

For more information on your vision benefits, please contact Davis Vision Customer Service at 877-923-2847

Need more information?   

Contact our Membership Services Department 972.726.0444 or 1.800.229.0304 See the last page for your enrollment form Visit our website at www.qcdofamerica.com

51

THE HARTFORD YOUR BENEFITS PACKAGE

Long Term Disability

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

DID YOU KNOW?

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

34.6 months is the duration of the average disability claim.

52

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Long Term Disability What is Long-Term Disability Insurance?

When is it effective?

Long-Term Disability Insurance pays you a portion of your earnings if you cannot work because of a disabling illness or injury. You have the opportunity to purchase Long-Term Disability Insurance through your employer. This highlight sheet is an overview of your Long-Term Disability Insurance.

Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

Why do I need Long-Term Disability Coverage?

Most accidents and injuries that keep people off the job happen outside the workplace and therefore are not covered by worker’s compensation. When you consider that nearly three in 10 workers entering the workforce today will become disabled before retiring1, it’s protection you won’t want to be without.

1 Social Security Administration, Fact Sheet 2009.

What is disability?

Disability is defined in The Hartford’s* contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings.

Once you have been disabled for 24 months, you must be prevented from performing one or more of the essential duties of any occupation and as a result, your current monthly earnings are 66 2/3% or less of your pre-disability earnings.

Am I eligible?

You are eligible if you are an active employee who works at least 20 hours per week on a regularly scheduled basis.

How much coverage would I have?

You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $8,000 that cannot exceed 66 2/3% of your current monthly earnings.

Your plan includes a minimum benefit of 25% of your elected benefit.

Earnings are defined in The Hartford’s contract with your employer.

When can I enroll?

If you choose not to elect coverage during your annual enrollment period, you will not be eligible to elect coverage until the next annual enrollment period without a qualifying change in family status.

What is does “Actively at Work” mean?

You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.

How long do I have to wait before I can receive my benefit?

You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Long-Term Disability benefit payment.

For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day.

What is an elimination period?

The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin.

I already have Disability coverage; do I have to do anything?

If you are not changing the amount of your coverage or your elimination period option, you do not have to do anything. If you want to purchase Long-Term Disability insurance for the first time or change your coverage, please be sure to complete the online enrollment, which indicates your election.

What other benefits are included in my disability coverage? 

Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment.

53

Long Term Disability 







Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse, or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit.

The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services.

Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services.

Identity Theft Protection – An array of identity fraud support services to help victims restore their identity.

Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.

How long will my disability payments continue? Can the duration of my benefit be reduced?

Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury.

Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of either the Premium or Select benefit option.

54

How long will my disability benefits continue if I elect the Premium benefit option?

Premium Option: For the Premium benefit option – the table below applies to disabilities resulting from sickness or injury: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

Benefits Payable To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months

How long will my disability benefits continue if I elect the Select benefit option?

Select Option: For the Select benefit option – see the tables below for the applicable benefit duration based on whether your disability is a result of injury or sickness.

Schedule for disability caused by injury: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

Benefits Payable To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months

Schedule for disability caused by sickness: Age Disabled

Benefits Payable

Prior to Age 65 Age 65 to 69 Age 69 and older

5 Years To Age 70, but not less than 1 year 1 Year

Long Term Disability Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:  War or act of war (declared or not)  Military service for any country engaged in war or other armed conflict  The commission of, or attempt to commit a felony  An intentionally self-inflicted injury  Any case where your being engaged in an illegal occupation was a contributing cause to your disability  You must be under the regular care of a physician to receive benefits.

Mental Illness, Alcoholism and Substance Abuse 



You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime.

Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:  Social Security Disability Insurance (please see next section for exceptions)  Workers' Compensation  Other employer-based Insurance coverage you may have  Unemployment benefits  Settlements or judgments for income loss  Retirement benefits that your employer fully or partially pays for (such as a pension plan.)

Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  Retirement benefits that are funded by your after-tax contributions  The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement.  Your personal savings, investments, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases

Pre-existing Conditions Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks.

55

THE HARTFORD

Voluntary Life and AD&D

YOUR BENEFITS PACKAGE

About this Benefit Life insurance provides a cash death benefit to your beneficiary upon your death. 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. If you are covered, you may apply for coverage on your spouse and eligible dependent children.

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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.

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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Supplemental Life Benefit Highlights What is supplemental life insurance?

Supplemental life insurance is coverage that you pay for. Supplemental life insurance pays your beneficiary (please see below) a benefit if you die while you are covered. This highlight sheet is an overview of your supplemental life insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be Actively at Work with your employer on the day your coverage takes effect.

How much supplemental life insurance can I purchase?

You can purchase supplemental life insurance in increments of $10,000.

The maximum amount you can purchase cannot be more than 7 times your annual salary or $500,000. Annual salary is as defined in The Hartford’s contract with your employer.

I already have supplemental life insurance coverage; do I have to do anything?

If you take no action, your coverage and coverage for your eligible dependents will automatically continue with The Hartford subject to the terms of the contract.

Am I guaranteed coverage?

If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $100,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your current coverage, you will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

Are there other limitations to enrollment?

If you do not enroll within 31 days of your first day of eligibility, you will be considered a “late entrant.” Typically, late entrants must show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required.

This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the Insurance coverage that you have elected may not be in effect.

If you elect supplemental life insurance for yourself, you may choose to purchase spouse supplemental life insurance in increments of $10,000, to a maximum of $350,000.

Coverage cannot exceed 100% of the amount of your employee voluntary/supplemental life insurance coverage. You may not elect coverage for your spouse if they are in active full-time military service or is already covered as an employee under this policy.

Spouse supplemental life insurance

If your spouse is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.

If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $20,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your spouse's current coverage, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective.

57

Supplemental Life Benefit Highlights

58

Child(ren) supplemental life insurance

If you elect supplemental life insurance for yourself, you may choose to purchase child(ren) supplemental life insurance coverage in increments of $5,000, to a maximum of $10,000 for each child – no medical information is required.  If your dependent child(ren) is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.  Your child(ren) must be at least 15 days but not yet age 26 to be covered.  Child(ren) age 26 or older may be covered if they were disabled prior to attaining age 26.  Child(ren) at least 15 days but not yet age 6 months are limited to a reduced benefit of $100.

Does my coverage reduce as I get older?

To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80. All coverage cancels at retirement.

Can I keep my Life Coverage if I leave my employer?

Yes, subject to the contract, you have the option of:  Converting your group life coverage to your own individual policy (policies).  If you leave your employer, Portability is an option that allows you to continue your life insurance coverage. To be eligible, you must terminate your employment prior to Social Security Normal Retirement Age. This option allows you to continue all or a portion of your Life Insurance coverage under a separate Portability term policy. Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does include coverage for your Spouse and Child(ren). To elect Portability, you must apply and pay the premium within 31 days of the termination of your Life Insurance. Evidence of Insurability will not be required.

Dependent Spouse Portability is subject to a maximum of $50,000.

Dependent Child Portability is subject to a maximum of $10,000.

What is the Living Benefits Option?

If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your Life Insurance. The remaining amount of your Life Insurance would be paid to your beneficiary when you die.

Do I still pay my Life Insurance premiums if I become disabled?

If you become totally disabled before age 60 and your disability lasts for at least 6 months, your Life Insurance premium may be waived. The premium for your dependent’s coverage will also be waived if you are disabled and approved for waiver of premium. Coverage for your dependents will end if the policy terminates.

Important Details

As is standard with most term life Insurance, this Insurance coverage includes limitations and exclusions:  The amount of your coverage may be reduced when you reach certain ages.  Death by suicide (two years).

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of Insurance will be available to explain your coverage in detail.

Voluntary AD&D Benefit Highlights

What is Voluntary Accidental Death and Dismemberment Insurance?

What does Voluntary AD&D Insurance cover?

Voluntary accidental death and dismemberment insurance pays your beneficiary (please see below) a death benefit if you die due to a covered accident while you are insured. It also pays you a benefit for certain accidental losses. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.  Death benefits are paid in addition to any life insurance benefits.  Voluntary accidental death and dismemberment insurance pays benefits for accidental loss of limbs, thumb and index finger, speech, hearing, and sight.  Voluntary accidental death and dismemberment insurance covers losses that occur away from work or at work. Benefits are paid regardless of any worker’s compensation benefits you collect.

This highlight sheet is an overview of your voluntary accidental death and dismemberment insurance.

You may receive benefits due to certain losses or death from an accident. The covered losses or death can occur up to 365 days after that accident. The policy pays for:  100% of the amount of coverage you purchase in the event of accidental loss of life, or speech and hearing in both ears.  One-half (50%) for accidental loss of one hand or foot, sight of one eye, or speech or hearing in both ears.  One-quarter (25%) for accidental loss of thumb and index finger of the same hand.

Additionally, your employer may have elected optional/supplemental benefits as part of your AD&D coverage. Refer to the certificate of insurance for further information.

Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase.

What optional benefits has my employer selected as part of my Voluntary AD&D Insurance?

        

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.

How much Voluntary AD&D Insurance can I purchase?

You can purchase Voluntary Accidental Death and Dismemberment Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than 10 times your annual salary or $500,000. Salary is as defined in The Hartford’s contract with your employer.

Accident Hospital Income Child Education Benefit Coma Benefit Common Disaster Benefit Day Care Benefit Paralysis Benefit Seat Belt & Air Bag Spouse Education Benefit Traumatic Brain Injury Benefit

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Voluntary AD&D Benefit Highlights Does my coverage reduce as I get To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80. older?

Do I have to provide medical information to receive coverage?

No medical information is required. You are guaranteed the amount of coverage that you select, subject to maximum amounts defined in your policy.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

You are automatically the beneficiary for any dependent coverage and for any AD&D losses other than life.

Are there other limitations to enrollment?

This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the insurance coverage that you have elected may not be in effect.

Voluntary Accidental Death and Dismemberment Insurance for your Dependents

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You may also choose voluntary accidental death and dismemberment insurance for your spouse and/or dependent child(ren). You may choose voluntary accidental death and dismemberment insurance for your spouse in the following amounts:  50% of the amount you select for yourself if you do not have any child(ren) whom you cover under this voluntary accidental death and dismemberment insurance policy.  40% if you have child(ren) whom you cover under this voluntary accidental death and dismemberment insurance policy.

You may not elect coverage for your spouse if your spouse is already covered as an employee under this policy. You may choose guaranteed voluntary accidental death and dismemberment insurance for each child from Live Birth but under age 25 (or age 25 if a full time student) in the following amounts:  15% of the amount you select for yourself if you do not have a spouse whom you cover under this voluntary accidental death and dismemberment insurance policy  10% if you have a spouse whom you cover under this voluntary accidental death and dismemberment insurance policy

Voluntary Life and AD&D Employee Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$100,000

$0.40 $0.40 $0.50 $0.60 $0.70 $1.00 $1.60 $2.90 $4.50 $8.60 $14.00 $14.00

$0.80 $0.80 $1.00 $1.20 $1.40 $2.00 $3.20 $5.80 $9.00 $17.20 $28.00 $28.00

$1.20 $1.20 $1.50 $1.80 $2.10 $3.00 $4.80 $8.70 $13.50 $25.80 $42.00 $42.00

$1.60 $1.60 $2.00 $2.40 $2.80 $4.00 $6.40 $11.60 $18.00 $34.40 $56.00 $56.00

$2.00 $2.00 $2.50 $3.00 $3.50 $5.00 $8.00 $14.50 $22.50 $43.00 $70.00 $70.00

$2.40 $2.40 $3.00 $3.60 $4.20 $6.00 $9.60 $17.40 $27.00 $51.60 $84.00 $84.00

$2.80 $2.80 $3.50 $4.20 $4.90 $7.00 $11.20 $20.30 $31.50 $60.20 $98.00 $98.00

$3.20 $3.20 $4.00 $4.80 $5.60 $8.00 $12.80 $23.20 $36.00 $68.80 $112.00 $112.00

$4.00 $4.00 $5.00 $6.00 $7.00 $10.00 $16.00 $29.00 $45.00 $86.00 $140.00 $140.00

Any amount over $100,000 will be medically underwritten. You must complete an Evidence of Insurability Form

Spouse Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$5,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

$50,000

$0.20 $0.20 $0.25 $0.30 $0.35 $0.50 $0.80 $1.45 $2.25 $4.30 $7.00 $7.00

$0.60 $0.60 $0.75 $0.90 $1.05 $1.50 $2.40 $4.35 $6.75 $12.90 $21.00 $21.00

$0.80 $0.80 $1.00 $1.20 $1.40 $2.00 $3.20 $5.80 $9.00 $17.20 $28.00 $28.00

$1.00 $1.00 $1.25 $1.50 $1.75 $2.50 $4.00 $7.25 $11.25 $21.50 $35.00 $35.00

$1.20 $1.20 $1.50 $1.80 $2.10 $3.00 $4.80 $8.70 $13.50 $25.80 $42.00 $42.00

$1.40 $1.40 $1.75 $2.10 $2.45 $3.50 $5.60 $10.15 $15.75 $30.10 $49.00 $49.00

$1.60 $1.60 $2.00 $2.40 $2.80 $4.00 $6.40 $11.60 $18.00 $34.40 $56.00 $56.00

$1.80 $1.80 $2.25 $2.70 $3.15 $4.50 $7.20 $13.05 $20.25 $38.70 $63.00 $63.00

$2.00 $2.00 $2.50 $3.00 $3.50 $5.00 $8.00 $14.50 $22.50 $43.00 $70.00 $70.00

NOTE: Rates for Spouse based on employeeâ&#x20AC;&#x2122;s Age Any amount over $20,000 will be medically underwritten. You must complete an Evidence of Insurability Form.

Child Life Rates Child(ren)

$5,000 $0.35

$10,000 $0.70

Stand Alone AD&D Employee EE + Family

$10,000 $0.24 $0.37

$20,000 $0.48 $0.74

$30,000 $0.72 $1.11

$40,000 $0.96 $1.48

$50,000 $1.20 $1.85

$60,000 $1.44 $2.22

$70,000 $1.68 $2.59

$80,000 $1.92 $2.96

$100,000 $2.40 $3.70

NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING. THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000.

FOR SPOUSE ANY INCREMENT OF $10,000 UP TO $350,000 (NOT TO EXCEED 100% OF EMPLOYEE SUPPLEMENTAL LIFE AMOUNT).

TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY ADD LEVELS TOGETHER. 61

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.

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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 Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

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. If you are participating in the Dependent Care portion, the money isn’t loaded to the card.

You must file web or paper claims or enroll in continual reimbursement.

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years.

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

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

For a list of sample expenses, please refer to the Keller ISD benefit website: www.mybenefitshub.com/kellerisd

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.

DID YOU KNOW?

FSA Annual Contribution Max:

FSAs use tax-free funds to help pay for your Health Care Expenses.

$2,400

Dependent Care Annual Max: $5,000

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

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

Online claims FAQs

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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/kellerisd

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What Happens If I Don’t Use All of My Funds by The End of the Plan Year (December 31st)?

Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it.

Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim?

In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/kellerisd 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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NOTES

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NOTES

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www.mybenefitshub.com/kellerisd

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