2016 Benefit Guide MRIC - Region 5

MULTI-REGIONAL INSURANCE COOPERATIVE

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

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Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Annual Enrollment 2. Eligibility Requirements 3. Helpful Definitions 4. Section 125 Cafeteria Plan Guidelines TRS-ActiveCare Medical APL MEDlink® Medical Supplement MDLIVE Telehealth Cigna Dental Superior Vision The Hartford Disability Loyal American Cancer AUL a OneAmerica Company Life and AD&D HSA Bank Health Savings Account (HSA) NBS Flexible Spending Account (FSA)

3 4-5 6-9 6 7 8 9 10-11 12-15 16-17 18-21 22-23 24-29 30-33 34-37 38-41 42-45

FLIP TO...

PG. 4 HOW TO ENROLL

PG. 8 HELPFUL DEFINITIONS

PG. 10 YOUR BENEFITS PACKAGE

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Benefit Contact Information

Benefit Contact Information MRIC BENEFITS

VISION

HEALTH SPENDING ACCOUNT

Financial Benefit Services (800) 583-6908 www.txescbenefits.com

Group # 27244-01/05 Superior Vision (800) 507-3800 www.superiorvision.com

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

MEDICAL

DISABILITY

FLEXIBLE SPENDING ACCOUNT

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

The Hartford (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

National Benefit Services (800) 274-1503 www.nbsbenefits.com

MEDICAL SUPPLEMENT—MEDLINK ®

CANCER

COBRA (DENTAL & VISION)

Group # 16613 American Public Life (800) 256-8606 www.ampublic.com

Policy # LY0281 Loyal American (800) 366-8354 www.loyalamerican.com

National Benefit Services (800) 274-1503 www.nbsbenefits.com

TELEHEALTH

LIFE AND AD&D

COBRA (MEDICAL)

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

Group # G00613435-0005 AUL a OneAmerica Company (800) 537-6442 www.oneamerica.com

WellSystems (844) 752-5146

DENTAL Group # 3309408 Cigna (800) 244-6224 www.mycigna.com

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How to Enroll On Your Device Enrollment has just become

SCAN:

easier!

Avoid typing long URLs and scan directly to your benefits websites, videos, and benefit guides.

Try it yourself! Scan the following code in the picture.

On Your Computer Access THEbenefitsHUB from your

Our online benefit enrollment

computer, tablet or smartphone!

platform provides a simple and easy to navigate process. Enroll at your own pace, whether at home or at work. www.txescbenefits.com 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

G O

www.txescbenefits.com

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

Username:

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

Annual Enrollment

Q&A

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

Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.



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

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



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

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

Where can I find forms?

For benefit summaries and claim forms, go to the MRIC benefit website: www.txescbenefits.com. Click on your service center, then click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the MRIC benefit website: www.txescbenefits.com. Click on your service center, then click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

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

   

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Login and complete your supplemental benefit enrollment from 07/14/2016 - 08/12/2016 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8 AM—5 PM from 07/14/2016—08/12/2016. Bilingual assistance is available.

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

IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the HUB. If you have questions, please contact your Benefits Administrator.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within the MRIC 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 2016 benefits become effective on September 1, 2016, you must be actively-at-work on September 1, 2016 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

26

Telehealth

MDLIVE

26

Dental

Cigna

26

Vision

Superior Vision

26

Cancer

Loyal American

25

Voluntary Life

AUL a OneAmerica Company

26

Flexible Spending Account

National Benefit Services

26 (benefits terminate at the end of the plan year following the birthday)

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

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Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

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(including diagnostic and/or consultation services).

SUMMARY PAGES

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

Enrollment is automatic unless you decline this benefit.

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

CHANGES IN STATUS (CIS): Marital Status

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

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

A change in number of dependents includes the following: birth, adoption and placement for adoption.

Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents 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 Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

Programs

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

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

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

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

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

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

$6,850 individual $13,700 family

$6,850 individual $13,700 family

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

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

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

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

Preventive Care See next page for a list of services

Plan pays 100%

Plan pays 100%

Plan pays 100%

Teladoc® Physician Services

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

Plan pays 100%

Plan pays 100%

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

20% after deductible

$100 copay plus 20% after deductible

$100 copay plus 20% after deductible

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

20% after deductible

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

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

Emergency Room (true emergency use) Participant pays

20% after deductible

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

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

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

Not covered

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

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

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

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

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

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

$20 $40** $65**

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

20% after deductible

$35 $60** 50% coinsurance**

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

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

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

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TRS-ActiveCare Plans—Preventive Care Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www. uspreventiveservicestaskforce.org/Page/Name/uspstf-a-andbrecommendations.

Plan pays 100% (deductible waived)

Some examples of preventive care frequency and services:  Routine physicals – annually Immunizations recommended by the Advisory Committee on age 12 and over Immunization Practices of the Centers for Disease Control and  Well-child care – unlimited Prevention (CDC) with respect to the individual involved. up to age 12 Evidence−informed preventive care and screenings provided  Well woman exam & pap for in the comprehensive guidelines supported by the Health smear – annually age 18 and Resources and Services Administration (HRSA) for infants, over children and adolescents. Additional preventive care and  Mammograms – 1 every year screenings for women, not described above, as provided for in age 35 and over comprehensive guidelines supported by the HRSA  Colonoscopy – 1 every 10 www.hhs.gov/healthcare/factsand- features/fact-sheets/ years age 50 and over preventive-services-covered-underaca/  Prostate cancer screening – 1 index.html#CoveredPreventiveServicesforAdults. per year age 50 and over  Smoking cessation For purposes of this benefit, the current recommendations of counseling – 8 visits per 12 the USPSTF regarding breast cancer screening and months mammography and prevention will be considered the most  Healthy diet/obesity current (other than those issued in or around November counseling – unlimited to age 2009).

22; age 22 and over-26 visits The preventive care services described above may change as per 12 months USPSTF, CDC and HRSA guidelines are modified.  Breastfeeding support – 6 lactation counseling visits per (Examples of covered services included are: 12 months Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.

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

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

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

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

Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices.

Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark.

To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800222-9205. The list may change as FDA guidelines are modified.

Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

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

$50 copay for specialist

Annual Hearing Examination Participant pays

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

$30 copay for primary $50 copay for specialist

$30 copay for primary $60 copay for specialist

Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health.

TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims.

Prescription drug benefits are administered by Caremark.

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AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

MEDlinkÂŽ

About this Benefit MEDlinkÂŽ is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co-payments and coinsurance of your medical plan.

DID YOU KNOW?

33% of total healthcare costs are paid out-of-pocket.

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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 MRIC Benefits Website: www.txescbenefits.com

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance MRIC Region 5 ESC

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

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 1

Maximum In-Hospital Benefits

$6,000 per Covered Person per Confinement

In-Hospital Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible

$0 per Covered Person per Confinement

Outpatient Benefit Rider Maximum Outpatient Benefits

$4,750 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible

$0 per Covered Person Per Occurrence

Covered Outpatient Services Hospital Emergency Room

Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility

Maximum of three Urgent Care visits per Covered Person per Calendar Year. Maximum of six Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Surgery

Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Diagnostic Testing

Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Benefit Rider Physician Outpatient Treatment Benefit Rider

$25 per visit; Maximum of four visits per Covered Person per Calendar Year and eight visits per Calendar Year for all Covered Persons combined for treatment in a: s Hospital Outpatient Facility s Freestanding Emergency Care Clinic s Urgent Care Facility/Clinic s Physician Office

Total Monthly Premiums by Plan* Ages 18+

Employee

Employee & Spouse

Employee & Child

Employee & Family

$118.64

$237.31

$205.23

$359.80

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

The premium and amount of benefits vary dependent upon the Plan selected at time of application.

APSB-22354(TX) MGM/FBS MRIC Region 5 ESC

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MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Important Policy Provisions

You are eligible to be covered under this Policy/Certificate if you are Actively At Work, qualify for coverage as defined in the Master Application, are covered under your Employer’s Medical Plan and are under age 70 (if you work for an employer employing less than 20 employees). Your Eligible Dependents, as defined in the Policy/Certificate, are eligible for coverage if they are covered under the Employer’s Medical Plan. You must apply for insurance during the Initial Enrollment period or on the date the person first becomes eligible for coverage. If you do not apply during the Initial Enrollment period or on the date you become eligible for coverage, you may be subject to additional underwriting by APL. Evidence of coverage under your Employer’s Medical Plan is required.

s committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.)

s participation in a contest of speed in power driven vehicles, parachuting or hang gliding;

s air travel, except:

s as a fare-paying passenger on a commercial airline on a regularly scheduled route; or

s as a passenger for transportation only and not as a pilot or crew member;

s being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.)

s alcoholism or drug addiction;

s sex changes;

s experimental treatment, drugs or surgery;

s Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.)

s dental or vision services, including treatment, surgery, extractions or x-rays, unless:

s resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or

s due to congenital disease or anomaly of a covered newborn

child.

s routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care;

s elective cosmetic surgery;

s drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider);

s sterilization and reversal of sterilization;

s an expense that does not meet the definition of Covered Charges;

s an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or

s any expense for which benefits are not payable under your Other Medical Plan.

Eligibility

When Coverage Begins

Coverage will begin on the requested Certificate Effective Date or the Certificate Effective Date assigned by us, upon approval of your application, if our underwriting rules are met, the premium has been paid and all persons to be insured are covered under your Employer’s Medical Plan and you are Actively At Work on the Certificate Effective Date. If you are not Actively At Work on the Certificate Effective Date due to disability, Injury, Sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to Actively At Work. No benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of the Insured’s Employer’s Medical Plan provision, described in the Policy.

Limitations & Exclusions A hospital is not an institution, or part thereof, used as: a place for rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Pre-Existing Condition Limitation

No benefits are payable during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date for any loss resulting from a Pre-Existing Condition. The Pre-Existing Condition Limitation will apply only if the Covered Person is subject to a Pre-Existing Condition Limitation under the Employer’s Medical Plan. Therefore, any Pre-Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan.

Exclusions

No benefits are payable for any loss resulting from or caused, whether directly or indirectly, by:

s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request)

s an intentionally self-inflicted Injury or Sickness;

s suicide or attempted suicide, while sane or insane;

s rest care or rehabilitative care and treatment;

s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse:

s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or

s where medical complications have arisen from abortion;

s pregnancy of an Eligible Dependent child;

s participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.)

14APSB-22354(TX) MGM/FBS MRIC Region 5 ESC

Premium Changes

The premium rates may be changed by APL at the first anniversary date of this Policy or any premium due date thereafter. No such increase in rates will be made unless 60 days prior notice is given to the Policyholder. Premiums will not increase during the initial 12 months of coverage.

Optionally Renewable

This Policy is renewable at the option of APL. The Policyholder or APL may terminate this Policy on any premium due date after the first anniversary following the Policy Effective Date, subject to 60 days written notice.

Termination of Certificate

Your insurance coverage under this Certificate and any attached riders will end on the earliest of these dates: s the date the Policy terminates; s the end of the grace period if the premium remains unpaid; s the date you no longer qualify as an Insured; s the date you attain age 70 (if you work for an employer employing less than 20 employees); s the date your coverage under your Employer’s Medical Plan ends; or s the date of your death.

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Termination of Coverage

Your insurance coverage under this Certificate and any attached riders for a Covered Person will end as follows: s the date the Policy terminates; s the date the Certificate terminates; s the end of the Certificate Month in which APL receives a written request from you to terminate the Covered Person’s coverage; s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or s the date of the Covered Person’s death.

APL may end the coverage of any Covered Person who submits a fraudulent claim.

Cobra Continuation of Coverage

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the certificate/policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Group Medical Expense Supplemental Insurance | (10/14) | MRIC Region 5 ESC

APSB-22354(TX) MGM/FBS MRIC Region 5 ESC

15

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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

DID YOU KNOW?

75%

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

16

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 MRIC Benefits Website: www.txescbenefits.com

Telehealth When should I use MDLIVE?  If you’re considering the ER or urgent care for a non-emergency medical issue  Your primary care physician is not available  At home, traveling, or at work  24/7/365, even holidays!

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

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

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

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

Are children eligible?

Yes. MDLIVE has local pediatricians on-call 24/7/365. However, a parent or guardian must be present during registration and any consultations involving minors.

How much does it cost? $0 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

Who are our providers ?

Our providers practice primary care, pediatrics, family and emergency medicine, and have incorporated MDLIVE into their practice to provide convenient access to quality care.

Scan with your smartphone to get the app.

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

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

17

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.

18

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 MRIC Benefits Website: www.txescbenefits.com

Dental PPO Total Cigna DPPO Network Benefits

Cigna Dental PPO In-Network

Out-of-Network

Calendar Year Maximum (Class I, II and III Expenses)

$1,000

$1,000

Contract Year Deductible Per Individual Per Family

$50 $150

$50 $150

Class I Expenses - Preventive & Diagnostic Care Oral Exams Cleanings Routine X-Rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Non-Routine X-Rays Emergency Care to Relieve Pain

100% No Deductible

100% No Deductible

80% After Deductible

80% After Deductible

Monthly PPO Premiums Tier

Rate

EE Only

$32.00

EE + Spouse

$58.00

EE + Child(ren)

$66.00

Family Coverage

$93.00

Class II Expenses - Basic Restorative Care Fillings Oral Surgery - Simple Extractions Oral Surgery - All Except Simple Extraction Anesthetics Relines, Rebases, and Adjustments Repairs - Bridges, Crowns, and Inlays Repairs - Dentures

Class III Expenses - Major Restorative Care Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Crowns / Inlays / Onlays Dentures Bridges Surgical Extraction of Impacted Teeth Prosthesis Over Implant

Class IV Expenses - Orthodontia Coverage for Dependent children to age 19 Lifetime Maximum

Missing Tooth Provision Late Entrant Limit Pretreatment Review Out-of-Network Reimbursement Dependent Age

12 Month Waiting Period

50% After Deductible

50% After Deductible

12 Month Waiting Period 50%, No Ortho Deductible $1,000

50%, No Ortho Deductible $1,000

No Limitation (teeth missing prior to the effective date of coverage are covered) 50% coverage on Class III and IV for 12 or 24 months Available on a voluntary basis when extensive work in excess of $200 is proposed.

90th Percentile 26/26

19

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

20

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

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

Dental PPO Procedure

Exclusions and Limitations

Exams Prophylaxis (Cleanings) Fluoride X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Prosthesis Over Implant

Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Bitewings: 2 per Calendar year Full mouth: 1 every 3 calendar years., Panorex: 1 every 3 calendar years Payable only when in conjunction with Ortho workup and extensive Perio treatment Various limitations depending on the service Various limitations depending on the service Replacement every 5 years 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 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 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

Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Sealants Space Maintainers Alternate Benefit

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Con necticut General Life Insurance Company.

"Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HPPOL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108.

“Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

21

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

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

DID YOU KNOW?

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

22

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 MRIC Benefits Website: www.txescbenefits.com

Vision Base Plan Co-Pays

Benefit Exam (ophthalmologist) Exam (optometrist) Frames Contact Lens Fitting (standard₂) Contact Lens Fitting (specialty₂) Contact Lenses4 Lenses (standard) per pair Single Vision Bifocal Trifocal Scratch coat (factory) Ultraviolet coat Progressive lens upgrade

Exam $10 Materials₁ $20 Contact Lens Fitting $20 Monthly Premiums EE Only $7.68 EE + Spouse $15.37 EE + Child(ren) $17.43 EE + Family $26.93 Services/Frequency Exam 12 months Frame 12 months Contact Lens Fitting 12 months Lenses 12 months Contact Lenses 12 months In-Network Out-of-Network Covered in full Up to $42 retail Covered in full Up to $37 retail $130 retail allowance Up to $52 retail Covered in full Not Covered $50 retail allowance Not Covered $130 retail allowance Up to $100 retail Covered in full Covered in full Covered in full Not covered Not covered See description3

₁ Materials co-pay applies to lenses & frames only, not contact lenses. ₂Visit FAQs on www.superiorvision.com for definitions of standard and specialty CLF. ₃Covered to the provider's retail amount for a standard lined trifocal lens; member pays the difference between the retail price of the progressive lens they have chose and their provider's standard lined trifocal lens, plus applicable co-pay.

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

Discounts on Covered Materials5 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.

Scratch coat Ultraviolet coat Tints, solid or gradients Anti-reflective coat Polycarbonate High index 1.6 Photochromics

Exam $5 Materials₁ $0 Contact Lens Fitting $0 Monthly Premiums EE Only $11.24 EE + Spouse $22.48 EE + Child(ren) $25.66 EE + Family $39.59 Services/Frequency Exam 12 months Frame 12 months Contact Lens Fitting 12 months Lenses 12 months Contact Lenses 12 months In-Network Out-of-Network Covered in full Up to $42 retail Covered in full Up to $37 retail $150 retail allowance Up to $60 retail Covered in full Not Covered $50 retail allowance Not Covered $200 retail allowance Up to $100 retail

Up to $26 retail Up to $34 retail Up to $50 retail Not covered Not covered Up to $100 retail

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

Frames: Lens options: Progressives:

Enhanced Plan Co-Pays

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal $13 $13 $15 $15 $25 $25 $50 $50 $40 20% off retail $55 20% off retail $80 20% off retail

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

Up to $26 retail Up to $34 retail Up to $50 retail Not covered Not covered Up to $50 retail

Discounts on Non-Covered Exam and Materials5 Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail 5Discounts

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.

23

THE HARTFORD

YOUR BENEFITS PACKAGE

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.

24

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 MRIC Benefits Website: www.txescbenefits.com

Long Term Disability Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. For specific details on how benefits are paid, refer to carrier brochure. Your disability coverage amount and premium can be accessed during your enrollment.



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.

Benefit Reductions 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 www.txescbenefits.com 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.)



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.

What other benefits are included in my disability coverage? 







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  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases

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.



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

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

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.

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.

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.

Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived.

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.

25

The Hartford Long Term Disability Premium Option: For the Premium benefit option – the table below applies to disabilities resulting from injury or sickness: 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

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days

26

Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400

$300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950

$200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300

$8.12 $12.18 $16.24 $20.30 $24.35 $28.41 $32.47 $36.53 $40.59 $44.65 $48.71 $52.77 $56.83 $60.89 $64.94 $69.00 $73.06 $77.12 $81.18 $85.24 $89.30 $93.36 $97.42 $101.48 $105.53 $109.59 $113.65 $117.71 $121.77 $125.83 $129.89 $133.95

$6.48 $9.72 $12.96 $16.20 $19.44 $22.68 $25.92 $29.16 $32.40 $35.64 $38.88 $42.12 $45.36 $48.60 $51.84 $55.08 $58.32 $61.56 $64.80 $68.04 $71.28 $74.52 $77.76 $81.00 $84.24 $87.48 $90.72 $93.96 $97.20 $100.44 $103.68 $106.92

$5.35 $8.02 $10.69 $13.37 $16.04 $18.71 $21.38 $24.06 $26.73 $29.40 $32.08 $34.75 $37.42 $40.10 $42.77 $45.44 $48.11 $50.79 $53.46 $56.13 $58.81 $61.48 $64.15 $66.83 $69.50 $72.17 $74.84 $77.52 $80.19 $82.86 $85.54 $88.21

$3.65 $5.48 $7.31 $9.14 $10.96 $12.79 $14.62 $16.44 $18.27 $20.10 $21.92 $23.75 $25.58 $27.41 $29.23 $31.06 $32.89 $34.71 $36.54 $38.37 $40.19 $42.02 $43.85 $45.68 $47.50 $49.33 $51.16 $52.98 $54.81 $56.64 $58.46 $60.29

$3.17 $4.75 $6.34 $7.92 $9.50 $11.09 $12.67 $14.26 $15.84 $17.42 $19.01 $20.59 $22.18 $23.76 $25.34 $26.93 $28.51 $30.10 $31.68 $33.26 $34.85 $36.43 $38.02 $39.60 $41.18 $42.77 $44.35 $45.94 $47.52 $49.10 $50.69 $52.27

$2.45 $3.67 $4.90 $6.12 $7.34 $8.57 $9.79 $11.02 $12.24 $13.46 $14.69 $15.91 $17.14 $18.36 $19.58 $20.81 $22.03 $23.26 $24.48 $25.70 $26.93 $28.15 $29.38 $30.60 $31.82 $33.05 $34.27 $35.50 $36.72 $37.94 $39.17 $40.39

The Hartford Long Term Disability

Annual Earnings $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000

Monthly Earnings $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650 $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Monthly Benefit 0/7 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180 $3,400 $138.01 $110.16 $90.88 $62.12 $53.86 $41.62 $3,500 $142.07 $113.40 $93.56 $63.95 $55.44 $42.84 $3,600 $146.12 $116.64 $96.23 $65.77 $57.02 $44.06 $3,700 $150.18 $119.88 $98.90 $67.60 $58.61 $45.29 $3,800 $154.24 $123.12 $101.57 $69.43 $60.19 $46.51 $3,900 $158.30 $126.36 $104.25 $71.25 $61.78 $47.74 $4,000 $162.36 $129.60 $106.92 $73.08 $63.36 $48.96 $4,100 $166.42 $132.84 $109.59 $74.91 $64.94 $50.18 $4,200 $170.48 $136.08 $112.27 $76.73 $66.53 $51.41 $4,300 $174.54 $139.32 $114.94 $78.56 $68.11 $52.63 $4,400 $178.60 $142.56 $117.61 $80.39 $69.70 $53.86 $4,500 $182.66 $145.80 $120.29 $82.22 $71.28 $55.08 $4,600 $186.71 $149.04 $122.96 $84.04 $72.86 $56.30 $4,700 $190.77 $152.28 $125.63 $85.87 $74.45 $57.53 $4,800 $194.83 $155.52 $128.30 $87.70 $76.03 $58.75 $4,900 $198.89 $158.76 $130.98 $89.52 $77.62 $59.98 $5,000 $202.95 $162.00 $133.65 $91.35 $79.20 $61.20 $5,100 $207.01 $165.24 $136.32 $93.18 $80.78 $62.42 $5,200 $211.07 $168.48 $139.00 $95.00 $82.37 $63.65 $5,300 $215.13 $171.72 $141.67 $96.83 $83.95 $64.87 $5,400 $219.19 $174.96 $144.34 $98.66 $85.54 $66.10 $5,500 $223.25 $178.20 $147.02 $100.49 $87.12 $67.32 $5,600 $227.30 $181.44 $149.69 $102.31 $88.70 $68.54 $5,700 $231.36 $184.68 $152.36 $104.14 $90.29 $69.77 $5,800 $235.42 $187.92 $155.03 $105.97 $91.87 $70.99 $5,900 $239.48 $191.16 $157.71 $107.79 $93.46 $72.22 $6,000 $243.54 $194.40 $160.38 $109.62 $95.04 $73.44 $6,100 $247.60 $197.64 $163.05 $111.45 $96.62 $74.66 $6,200 $251.66 $200.88 $165.73 $113.27 $98.21 $75.89 $6,300 $255.72 $204.12 $168.40 $115.10 $99.79 $77.11 $6,400 $259.78 $207.36 $171.07 $116.93 $101.38 $78.34 $6,500 $263.84 $210.60 $173.75 $118.76 $102.96 $79.56 $6,600 $267.89 $213.84 $176.42 $120.58 $104.54 $80.78 $6,700 $271.95 $217.08 $179.09 $122.41 $106.13 $82.01 $6,800 $276.01 $220.32 $181.76 $124.24 $107.71 $83.23 $6,900 $280.07 $223.56 $184.44 $126.06 $109.30 $84.46 $7,000 $284.13 $226.80 $187.11 $127.89 $110.88 $85.68 $7,100 $288.19 $230.04 $189.78 $129.72 $112.46 $86.90 $7,200 $292.25 $233.28 $192.46 $131.54 $114.05 $88.13 $7,300 $296.31 $236.52 $195.13 $133.37 $115.63 $89.35 $7,400 $300.37 $239.76 $197.80 $135.20 $117.22 $90.58 $7,500 $304.43 $243.00 $200.48 $137.03 $118.80 $91.80 $7,600 $308.48 $246.24 $203.15 $138.85 $120.38 $93.02 $7,700 $312.54 $249.48 $205.82 $140.68 $121.97 $94.25 $7,800 $316.60 $252.72 $208.49 $142.51 $123.55 $95.47 $7,900 $320.66 $255.96 $211.17 $144.33 $125.14 $96.70 $324.72 $259.20 $213.84 $146.16 $126.72 $8,000 $97.92 27

The Hartford Long Term Disability 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 Prior to Age 65 Age 65 to 69 Age 69 and older

Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 28

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950

Benefits Payable 5 Years To Age 70, but not less than one year 1 Year MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Monthly Benefit 0/7 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180 $200 $7.24 $5.72 $4.79 $3.26 $2.83 $2.18 $300 $10.85 $8.59 $7.18 $4.89 $4.24 $3.27 $400 $14.47 $11.45 $9.58 $6.52 $5.65 $4.36 $500 $18.09 $14.31 $11.97 $8.15 $7.07 $5.45 $600 $21.71 $17.17 $14.36 $9.77 $8.48 $6.53 $700 $25.33 $20.03 $16.76 $11.40 $9.89 $7.62 $800 $28.94 $22.90 $19.15 $13.03 $11.30 $8.71 $900 $32.56 $25.76 $21.55 $14.66 $12.72 $9.80 $1,000 $36.18 $28.62 $23.94 $16.29 $14.13 $10.89 $1,100 $39.80 $31.48 $26.33 $17.92 $15.54 $11.98 $1,200 $43.42 $34.34 $28.73 $19.55 $16.96 $13.07 $1,300 $47.03 $37.21 $31.12 $21.18 $18.37 $14.16 $1,400 $50.65 $40.07 $33.52 $22.81 $19.78 $15.25 $1,500 $54.27 $42.93 $35.91 $24.44 $21.20 $16.34 $1,600 $57.89 $45.79 $38.30 $26.06 $22.61 $17.42 $1,700 $61.51 $48.65 $40.70 $27.69 $24.02 $18.51 $1,800 $65.12 $51.52 $43.09 $29.32 $25.43 $19.60 $1,900 $68.74 $54.38 $45.49 $30.95 $26.85 $20.69 $2,000 $72.36 $57.24 $47.88 $32.58 $28.26 $21.78 $2,100 $75.98 $60.10 $50.27 $34.21 $29.67 $22.87 $2,200 $79.60 $62.96 $52.67 $35.84 $31.09 $23.96 $2,300 $83.21 $65.83 $55.06 $37.47 $32.50 $25.05 $2,400 $86.83 $68.69 $57.46 $39.10 $33.91 $26.14 $2,500 $90.45 $71.55 $59.85 $40.73 $35.33 $27.23 $2,600 $94.07 $74.41 $62.24 $42.35 $36.74 $28.31 $2,700 $97.69 $77.27 $64.64 $43.98 $38.15 $29.40 $2,800 $101.30 $80.14 $67.03 $45.61 $39.56 $30.49 $2,900 $104.92 $83.00 $69.43 $47.24 $40.98 $31.58 $3,000 $108.54 $85.86 $71.82 $48.87 $42.39 $32.67 $3,100 $112.16 $88.72 $74.21 $50.50 $43.80 $33.76 $3,200 $115.78 $91.58 $76.61 $52.13 $45.22 $34.85 $3,300 $119.39 $94.45 $79.00 $53.76 $46.63 $35.94

The Hartford Long Term Disability

Annual Earnings $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000

Monthly Earnings $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650 $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Monthly Benefit 0/7 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180 $3,400 $123.01 $97.31 $81.40 $55.39 $48.04 $37.03 $3,500 $126.63 $100.17 $83.79 $57.02 $49.46 $38.12 $3,600 $130.25 $103.03 $86.18 $58.64 $50.87 $39.20 $3,700 $133.87 $105.89 $88.58 $60.27 $52.28 $40.29 $3,800 $137.48 $108.76 $90.97 $61.90 $53.69 $41.38 $3,900 $141.10 $111.62 $93.37 $63.53 $55.11 $42.47 $4,000 $144.72 $114.48 $95.76 $65.16 $56.52 $43.56 $4,100 $148.34 $117.34 $98.15 $66.79 $57.93 $44.65 $4,200 $151.96 $120.20 $100.55 $68.42 $59.35 $45.74 $4,300 $155.57 $123.07 $102.94 $70.05 $60.76 $46.83 $4,400 $159.19 $125.93 $105.34 $71.68 $62.17 $47.92 $4,500 $162.81 $128.79 $107.73 $73.31 $63.59 $49.01 $4,600 $166.43 $131.65 $110.12 $74.93 $65.00 $50.09 $4,700 $170.05 $134.51 $112.52 $76.56 $66.41 $51.18 $4,800 $173.66 $137.38 $114.91 $78.19 $67.82 $52.27 $4,900 $177.28 $140.24 $117.31 $79.82 $69.24 $53.36 $5,000 $180.90 $143.10 $119.70 $81.45 $70.65 $54.45 $5,100 $184.52 $145.96 $122.09 $83.08 $72.06 $55.54 $5,200 $188.14 $148.82 $124.49 $84.71 $73.48 $56.63 $5,300 $191.75 $151.69 $126.88 $86.34 $74.89 $57.72 $5,400 $195.37 $154.55 $129.28 $87.97 $76.30 $58.81 $5,500 $198.99 $157.41 $131.67 $89.60 $77.72 $59.90 $5,600 $202.61 $160.27 $134.06 $91.22 $79.13 $60.98 $5,700 $206.23 $163.13 $136.46 $92.85 $80.54 $62.07 $5,800 $209.84 $166.00 $138.85 $94.48 $81.95 $63.16 $5,900 $213.46 $168.86 $141.25 $96.11 $83.37 $64.25 $6,000 $217.08 $171.72 $143.64 $97.74 $84.78 $65.34 $6,100 $220.70 $174.58 $146.03 $99.37 $86.19 $66.43 $6,200 $224.32 $177.44 $148.43 $101.00 $87.61 $67.52 $6,300 $227.93 $180.31 $150.82 $102.63 $89.02 $68.61 $6,400 $231.55 $183.17 $153.22 $104.26 $90.43 $69.70 $6,500 $235.17 $186.03 $155.61 $105.89 $91.85 $70.79 $6,600 $238.79 $188.89 $158.00 $107.51 $93.26 $71.87 $6,700 $242.41 $191.75 $160.40 $109.14 $94.67 $72.96 $6,800 $246.02 $194.62 $162.79 $110.77 $96.08 $74.05 $6,900 $249.64 $197.48 $165.19 $112.40 $97.50 $75.14 $7,000 $253.26 $200.34 $167.58 $114.03 $98.91 $76.23 $7,100 $256.88 $203.20 $169.97 $115.66 $100.32 $77.32 $7,200 $260.50 $206.06 $172.37 $117.29 $101.74 $78.41 $7,300 $264.11 $208.93 $174.76 $118.92 $103.15 $79.50 $7,400 $267.73 $211.79 $177.16 $120.55 $104.56 $80.59 $7,500 $271.35 $214.65 $179.55 $122.18 $105.98 $81.68 $7,600 $274.97 $217.51 $181.94 $123.80 $107.39 $82.76 $7,700 $278.59 $220.37 $184.34 $125.43 $108.80 $83.85 $7,800 $282.20 $223.24 $186.73 $127.06 $110.21 $84.94 $7,900 $285.82 $226.10 $189.13 $128.69 $111.63 $86.03 $8,000 $289.44 $228.96 $191.52 $130.32 $113.04 $87.12 29

LOYAL AMERICAN

Cancer

YOUR BENEFITS PACKAGE

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

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

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

30

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 MRIC Benefits Website: www.txescbenefits.com

Cancer ADDITIONAL BENEFIT AMOUNTS

Maximum

ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the Actual Charge,, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

B.

Additional Benefit

We will pay the Actual Charge, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate.

FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule.

If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.

$50 Per Calendar Year

$100 Per Calendar Year

$2,000 Once per Lifetime $3,000 Once per Lifetime

DAILY RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG6045) We will pay the Actual Charge, but not to exceed the maximum benefit amount shown on the Certificate Schedule for each day that an Insured Person receives one or more of the following treatments for Cancer: (1) Chemotherapy (including Hormonal Therapy) or Immunotherapy; (2) Self-injected Chemotherapy or Immunotherapy drugs, limited to the maximum daily benefit amount per treatment; (3) Chemotherapy or Immunotherapy drugs dispensed by a pump or implant, limited to the maximum daily benefit amount for the initial prescription and an equal amount for each refill; (4) Oral Chemotherapy or Immunotherapy, limited to the maximum daily benefit amount per prescription; (5) Radiation Treatment. Benefits payable for interstitial or intracavitary applications of Radiation Treatments are payable on the day of insertion only and not for each day the Radiation Treatment remains in the body; or (6) Experimental Treatment. The benefit amount shown on the Certificate Schedule is the maximum daily benefit available per Insured Person regardless of the number or types of Cancer treatments received on the same day.

$600 Per Day

SURGICAL BENEFIT RIDER (form LG-6048) Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.

$5,000 Procedure Maximum

Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed.

This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.

$1,250 Procedure Maximum

Breast Reconstruction With transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.

$4,500 Procedure Maximum

Skin Cancer Surgery Expense We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.

Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.

Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.

Per Procedure

$200 Per Day

$400 Per Day

$400/ $800 Per Day

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Cancer Additional Benefits Amounts SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider.

Covers These 38 Specified Diseases Addison’s Disease Amyotrophic Lateral Sclerosis Botulism Bovine Spongiform Encephalopathy Budd-Chiari Syndrome Cystic Fibrosis Diptheria Encephalitis Epilepsy Hansen’s Disease Histoplasmosis Legionnaire’s Disease Lyme Disease

Lupus Erythematosus Malaria Meningitis Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Neimann-Pick Disease Osteomyelitis Poliomyelitis Q Fever Rabies Reye’s Syndrome Rheumatic Fever

Rocky Mountain Spotted Fever Sickle Cell Anemia Tay-Sachs Disease Tetanus Toxic Epidermal Necrolysis Tuberculosis Tularemia Typhoid Fever Undulant Fever West Nile Virus Whipple’s Disease Whooping Cough

Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage.

Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person.

Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement.

If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more. *SPECIFIED DISEASE BENEFIT RIDER IS NOT INCLUDED IN PLAN A

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Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Base Plan

$22.86

$27.86

$38.50

$38.50

Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047)* Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.

$1,000 Per Day

Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided $2,000 that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related Per Day injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.

Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.

$500 Per Day

Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement.

ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75.

Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner.

THIS IS A LIMITED RIDER.

Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Base Plan with ICU

$25.19

$31.05

$42.90

$42.90

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AUL A ONEAMERICA COMPANY

YOUR BENEFITS PACKAGE

Life and AD&D

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family.

Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident.

Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

34

DID YOU KNOW? Motor vehicle crashes are the

#1

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

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

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

A $25,000 Life and AD&D insurance policy is provided to all full-time employees of ESC Region 5 at no cost.

Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns Optional Guaranteed issue amounts of dependent coverage as follows:

Dependent Type

Option 1

Option 2

Spouse under age 70

$5,000

$10,000

Dependent Child*—6 months to under age 26 years

$1,000

$2,000

Dependent Child—live birth to under 6 months

$1,000

$1,000

At a premium cost for Family:

$1.33 Monthly

$2.67 Monthly

*Age and Definition of Child(ren) may vary by state.

Supplemental Life Coverage   

You may select a minimum of $15,000 to a maximum of $75,000 in increments of $15,000, not to exceed 7 times your annual base salary.

Waiver of premium benefit Accelerated life benefit

Coverage Amounts

Monthly

$15,000

$1.65

$30,000

$3.30

$45,000

$4.95

$60,000

$6.60

$75,000

$8.25

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

You may select a minimum benefit of $10,000 to a maximum benefit amount of $500,000, in increments of $1,000, not to exceed 7 times your annual base salary.

Employee must select coverage to select any Dependent coverage.

Amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability.

The Spouse benefit is equal to 50% of the amount elected by the Employee; the Child benefit is equal to 10% of the amount elected by the Employee.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) 0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$0.45

$0.45

$0.45

$0.75

$0.95

$1.45

$2.35

$3.60

$5.60

$8.20

$16.00

$16.00

$16.00

$20,000

$0.90

$0.90

$0.90

$1.50

$1.90

$2.90

$4.70

$7.20

$11.20

$16.40

$32.00

$32.00

$32.00

$30,000

$1.35

$1.35

$1.35

$2.25

$2.85

$4.35

$7.05

$10.80

$16.80

$24.60

$48.00

$48.00

$48.00

$40,000

$1.80

$1.80

$1.80

$3.00

$3.80

$5.80

$9.40

$14.40

$22.40

$32.80

$64.00

$64.00

$64.00

$50,000

$2.25

$2.25

$2.25

$3.75

$4.75

$7.25

$11.75 $18.00

$28.00

$41.00

$80.00

$80.00

$80.00

$80,000

$3.60

$3.60

$3.60

$6.00

$7.00

$11.60 $18.80 $28.80

$44.80

$65.60 $128.00 $128.00 $128.00

$100,000

$4.50

$4.50

$4.50

$7.50

$9.50

$14.50 $23.50 $36.00

$56.00

$82.00 $160.00 $160.00 $160.00

$150,000

$6.75

$6.75

$6.75

$11.25 $14.25 $21.75 $35.25 $54.00

$200,000

$9.00

$9.00

$9.00

$15.00 $19.00 $29.00 $47.00 $72.00 $112.00 $164.00 $320.00 $320.00 $320.00

$84.00 $123.00 $240.00 $240.00 $240.00

SPOUSE ONLY OPTIONS Spouse premium based on Employee's age and amount of coverage chosen.

Spouse coverage amount cannot exceed 100% of employee amount

36

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

$10,000

$0.45

$0.45

$0.45

$0.75

$0.95

$1.45

$2.35

$3.60

$5.60

$8.20

$16.00

$16.00 $16.00

75+

$15,000

$0.68

$0.68

$0.68

$1.13

$1.43

$2.18

$3.53

$5.40

$8.40

$12.30

$24.00

$24.00 $24.00

$20,000

$0.90

$0.90

$0.90

$1.50

$1.90

$2.90

$4.70

$7.20

$11.20

$16.40

$32.00

$32.00 $32.00

$25,000

$1.13

$1.13

$1.13

$1.88

$2.38

$3.63

$5.88

$9.00

$14.00

$20.50

$40.00

$40.00 $40.00

$30,000

$1.35

$1.35

$1.35

$2.25

$2.85

$4.35

$7.05

$10.80

$16.80

$24.60

$48.00

$48.00 $48.00

$35,000

$1.58

$1.58

$1.58

$2.63

$3.33

$5.08

$8.23

$12.60

$19.60

$28.70

$56.00

$56.00 $56.00

$40,000

$1.80

$1.80

$1.80

$3.00

$3.80

$5.80

$9.40

$14.40

$22.40

$32.80

$64.00

$64.00 $64.00

$45,000

$2.03

$2.03

$2.03

$3.38

$4.28

$6.53 $10.58 $16.20

$25.20

$36.90

$72.00

$72.00 $72.00

$50,000

$2.25

$2.25

$2.25

$3.75

$4.75

$7.25 $11.75 $18.00

$28.00

$41.00

$80.00

$80.00 $80.00

Life and AD&D CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Child(ren) 6 months to age 26

Monthly Payroll Deduction Life Amount

Child(ren) live birth to 6 months

Option 1:

$5,000

$1,000

$1.00

Option 2:

$10,000

$1,000

$2.00

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance Company® (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.

Voluntary Term AD&D Coverage About your benefit options:   

You may select a minimum benefit of $10,000 up to a maximum benefit amount of $500,000, in increments of $25,000, not to exceed 10 times your annual base salary.

Employee must select coverage to select any Dependent coverage.

The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.

Employee Only AD&D

Family AD&D

Volume

Monthly Deduction

Employee Volume

Spouse Volume

Child Volume

Monthly Deduction

$25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $375,000 $400,000 $425,000 $450,000 $475,000 $500,000

$0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $9.10 $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00

$25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $375,000 $400,000 $425,000 $450,000 $475,000 $500,000

$12,500 $25,000 $37,500 $50,000 $62,500 $75,000 $87,500 $100,000 $112,500 $125,000 $137,500 $150,000 $162,500 $175,000 $187,500 $200,000 $212,500 $225,000 $237,500 $250,000

$2,500 $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 $27,500 $30,000 $32,500 $35,000 $37,500 $40,000 $42,500 $45,000 $47,500 $50,000

$0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $9.10 $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 37

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

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

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

Money withdrawn for medical spending never falls under taxable income.

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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 MRIC Benefits Website: www.txescbenefits.com

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an  Not enrolled in Medicare (if an accountholder enrolls in affordable health coverage option that helps you save on Medicare mid-year, catch-up contributions should be healthcare expenses. This plan is only available for those who are prorated) participating in the Active Care 1-HD medical plan. You may not Authorized Signers who are 55 or older must have their own enroll in the MEDlink® plan if you participate in the HSA. HSA in order to make the catch-up contribution Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Monthly Fee: Your account will be charged a monthly fee of Medicaid, and Tricare participants are not eligible to participate $1.75, waived with an average daily balance at or above in an HSA. $3,000.

You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 

A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income.

Unused funds that will roll over year to year. There’s no “use it or lose it” penalty.

A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the MRIC website at www.txescbenefits.com.

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

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

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder  Age 55 or older (regardless of when in the year an accountholder turns 55)

39

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

How an HSA works: 



 

You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well.

You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings.

Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes).

Check balances and account information via HSA Bank’s Internet Banking 24/7.

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

When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits?

Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS).

Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2.

40

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

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution.

According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

How can you benefit from tax savings?

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

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents.

An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

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

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

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

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

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed.

3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions.

4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”.

Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional.

5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

41

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA).

Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.

42

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 MRIC Benefits Website: www.txescbenefits.com

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. If you need a replacement card please contact NBS directly at (800) 274-0503.

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

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

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

For a list of sample expenses, please refer to the MRIC benefit website: www.txescbenefits.com

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

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

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com

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

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

Online claim FAQs 43

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.txescbenefits.com

44

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

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

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

Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.

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.txescbenefits.com and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

How To Receive Your Dependent Care Reimbursement Faster.

A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!

How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited.

However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1.

2.

3.

4.

Complete and sign a claim form (available on our website) or an online claim.

Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider.

Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

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

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

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

45

NOTES

46

NOTES

47

www.txescbenefits.com

48