Page 1

ESC REGION 20 BENEFITS COOPERATIVE

BENEFIT GUIDE EFFECTIVE: 09/01/2018 - 8/31/2019 WWW.ESC20BC.NET

1


Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) MDLIVE Telehealth AFLAC Hospital Indemnity APL Accident Cigna Dental Superior Vision OneAmerica Short Term Disability OneAmerica Long Term Disability APL Cancer 5Star Individual Life OneAmerica Life and AD&D AFLAC Critical Illness HSA Bank Health Savings Account (HSA) NBS Flexible Spending Account (FSA) MASA Medical Transport ID Watchdog Identity Theft 2

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

FLIP TO... PG. 4 HOW TO HOW TO ENROLL ENROLL

11 12-13 14-17 18-21 22-27 28-29 30-33 34-37 38-41 42-45 46-51 52-55 56-59 60-63 64-65 66-67

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS


Benefit Contact Information ESC REGION 20 BC BENEFITS

SHORT TERM DISABILITY

HEALTH SAVINGS ACCOUNT

Financial Benefit Services (800) 583-6908 www.esc20bc.net

OneAmerica (800) 583-6908 www.cigna.com

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

TELEHEALTH

LONG TERM DISABILITY

FLEXIBLE SPENDING ACCOUNT

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

OneAmerica (800) 583-6908 www.cigna.com

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

HOSPITAL INDEMNITY

CANCER

MASA MEDICAL TRANSPORT

Aflac (800) 992-3522 www.aflac.com

Group #13309 American Public Life (800) 256-8606 www.ampublic.com

MASA (800) 423-3226 www.masamts.com

ACCIDENT

INDIVIDUAL LIFE

IDENTITY THEFT

Group #13309 American Public Life (800) 256-8606 www.ampublic.com

5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com

ID Watchdog (800) 237-1521 www.idwatchdog.com

DENTAL

LIFE AND AD&D

MEDICAL

Group #3336975 Cigna (800) 244-6224 www.mycigna.com

OneAmerica (800) 583-6908 www.cigna.com

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

VISION

CRITICAL ILLNESS

Group #28888 Superior Vision (800) 507-3800 www.superiorvision.com

Aflac 800-992-3522 www.aflac.com

3


MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS ESC20” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information

Online Support

Interactive Tools

And more. PLAY VIDEO

4

Text “FBS ESC20” to 313131 OR SCAN


How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.esc20bc.net

CLICK LOGIN

ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below:

Username: 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.

ONLIINE SUPPORT

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.

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

5


Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

Benefit elections will become elective 9/1/2018.  Elections requiring evidence of insurability, such as Life Insurance, may have a later elective date, if approved. After annual enrollment, benefit changes can only be made if you experience a qualifying event. Changes must be made within 30 days of event.

If you currently participate in a Healthcare or Dependent Care Flexible Spending Account, you MUST  re-elect a new contribution amount in the summer enrollment to continue to participate .

Your current monthly HSA contribution will rollover to next plan year unless you make a change to your election during the summer enrollment window.

Change: Effective 9/1/2018, Cigna Dental premium will have a slight increase for the high, Low PPO and DHMO plans

NEW! Hospital Indemnity—Hospital Indemnity insurance is designed to supplement your medical coverage, easing the financial impact by covering some of the additional expenses associated with a hospital stay. It provides cash benefits paid directly to you for hospitalization. Two Plans to choose from- High and Low op ons. NEW! Group Life Insurance—The group life carrier will be changing from Cigna to One America/ AUL. They will take over all current group life coverage at current benefit levels and rates. Guaranteed Issue will be offered this year on new (or increased) coverage: up to $200K for employee, $50K on spouse, and $10K on children.

Don’t Forget! 

Login and complete your benefit enrollment by August 24th.

Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative Monday—Friday between 8am – 5pm CST

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

Update dependent social security numbers and student status for college aged children

6


SUMMARY PAGES

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

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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

7


SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to the ESC Region

Changes are not permitted during the plan year (outside of

20 BC benefit website: www.esc20bc.net. Click on your school

annual enrollment) unless a Section 125 qualifying event occurs.

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

Changes, additions or drops may be made only during the

the Benefits and Forms section.

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

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

20 BC benefit website: www.esc20bc.net. Click on your school

included in the dependent profile. Additionally, you must

district, then click on the benefit plan you need information

notify your employer of any discrepancy in personal and/or benefit information.

For benefit summaries and claim forms, go to the ESC Region

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.

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

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

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

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

8


SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 18.75 or

Dependent Eligibility: You can cover eligible dependent

more 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 ESC Region 20 BC or as

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

both employees and dependents.

work concurrent with the plan effective date. For example, if your 2018 benefits become effective on September 1, 2018, you must be actively-at-work on September 1, 2018 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

Accident

American Public Life

Through 25

Cancer

American Public Life

Through 25

Dental

Cigna

Through 25

Dependent Flex

National Benefit Services

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

Healthcare FSA

National Benefit Services

Through 25 or IRS Tax Dependent

Health Savings Account

HSA Bank

IRS Tax Dependent

Identity Theft

ID Watchdog

Through 25

Medical Supplement Plan

American Public Life

Through 25

Permanent Life

5Star

Through 25

Telehealth

MDLIVE

Through 25

Vision

Superior Vision

Through 25

Voluntary Life

Cigna

Through 25

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. 9


SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2018 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.

10

(including diagnostic and/or consultation services).


SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

$1,000 single (2018) $2,600 family (2018) $3,450 single (2018) $6,900 family (2018) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

N/A $2,650 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

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

Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

No

Portable?

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

No

FLIP TO FOR HSA INFORMATION

PG. 56

FLIP TO FOR FSA INFORMATION

PG. 60

11


MDLIVE YOUR BENEFITS PACKAGE

Telehealth

PLAY VIDEO

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.

75%

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 12 ESC Region 20 BC Benefits Website: www.esc20bc.net


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

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

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

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

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

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

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

How much does it cost? $8 for Employee Only. $16 for Family.

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

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 13 abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/terms-of-use/ 010113


AFLAC YOUR BENEFITS PACKAGE

Hospital Indemnity

PLAY VIDEO

About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

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

$8,800

9,600

10,400

2003

2008

2012

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 14 ESC Region 20 BC Benefits Website: www.esc20bc.net


Hospital Indemnity Benefit Amounts Coverage

Features and Plan Provisions See Premium Rates and Plan Benefits for available options Available for all family members. Spouse-only and Child-only coverage is not available

Guaranteed-issue coverage is offered to all eligible applicants during the initial enrollGuaranteed Issue Amounts ment and for new hires thereafter. At the group's first anniversary, late enrollees are eligible to enroll on a guaranteed-issue basis. Enrollment Assumptions Enrollments take place once each 12-month period. Late enrollees cannot enroll outside of an annual enrollment period. Payment Method Payroll Deducted Pre-existing Condition Exclusion None Pregnancy Limitation None Waiting Period There is no waiting period Benefit Reductions No reduction at any age Portability/Continuation Standard Employees must be actively-at-work on the application date and the effective date. Eligibility They must work at least 16 hours per week. Seasonal and temporary employees are not eligible. Dependents are eligible, but only if the employee is eligible and participates. Successor Insured Included Successor Insured Waiver of Not Included Premium Low Plan: Employee & Spouse: 18-69; Children: Under age 26 Issue Ages High Plan: Employee & Spouse: 18+ ; Children: Under age 26 Termination Age Low Plan: Terminates at Age 70 High Plan: None Certificate Effective Date Coverage is effective on the billing effective date Benefits Summary Hospital Admission

Hospital Confinement

Hospital Intensive Care

Payable when an insured is admitted to a hospital and confined as an inpatient because of a covered accidental injury or because of a covered sickness. Not payable for confinement to an observation unit, or for emergency room treatment or outpatient treatment. Payable for each day that an insured is confined to a hospital as an inpatient as the result of a covered accidental injury or because of a covered sickness. If we pay benefits for confinement and the insured becomes confined again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable for only one hospital confinement at a time even if caused by more than one covered accidental injury, more than one covered sickness, or a covered accidental injury and a covered sickness. Payable for each day that an insured is confined in a hospital intensive care unit because of a covered accidental injury or because of a covered sickness. We will pay benefits for only one confinement in a hospital's intensive care unit at a time, even if it is caused by more than one covered accidental injury, more than one covered sickness or a covered accidental injury and a covered sickness. If we pay benefits for confinement in a hospital's intensive care unit and an insured becomes confined to a hospital's intensive care unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable in addition to the Hospital Confinement Benefit.

15


Hospital Indemnity Benefit Summary

Intermediate Intensive Care Step-Down Unit

Payable for each day that an insured is confined in an intermediate intensive care step-down unit because of a covered accidental injury or because of a covered sickness. We will pay benefits for only one confinement in an intermediate intensive care step-down unit at a time, even if it is caused by more than one covered accidental injury, more than one covered sickness or a covered accidental injury and a covered sickness. If we pay benefits for confinement in a hospital's intermediate intensive care step-down unit and an insured becomes confined to a hospital's intermediate intensive care step-down unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable in addition to the Hospital Confinement Benefit. The insured must be admitted to a hospital within six months of the date of the covered accident for benefits to be payable.

Health Screening Benefit

Payable for health screening tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for each insured.

Hospital Benefit

Low Plan

High Plan

$1,000

$2,000

Hospital Confinement (per day) Maximum confinement period: 30 days per covered sickness or covered accident

$100

$200

Health Screening Benefit

Low Plan

High Plan

$50

$50

Hospital Admission (per confinement) Once per covered sickness or accident per calendar year

Payable once per calendar year per insured.

Monthly Premiums Coverage

16

Low Plan

High Plan

Employee

$17.44

$32.42

Employee + Spouse

$33.09

$65.48

Employee + Child(ren)

$26.78

$51.04

Family

$42.42

$84.10


Hospital Indemnity Limits & Exclusions We will not pay for loss due to: War - voluntarily participating in war, any act of war, or military conflicts, declared or undeclared, or voluntarily participating or serving in the military, armed forces, or an auxiliary unit thereto, or contracting with any country or international authority. (We will return the prorated premium for any period not covered by the certificate when the insured is in such service.) War also includes voluntary participation in an insurrection, riot, civil commotion or civil state of belligerence. War does not include acts of terrorism (except in Illinois).  In California: voluntarily participating in war, any act of war, or military conflicts, declared or undeclared, or voluntarily participating or serving in the military, armed forces, or an auxiliary unit thereto, or contracting with any country or international authority. (We will return the prorated premium for any period not covered by the certificate when the Insured is in such service.) War also includes voluntary participation in an insurrection, or riot.  In Connecticut: a riot is not excluded.

professional capacity.

 In California: participating in any organized sport in a professional capacity  In Idaho: participating in any professional organized sport. Custodial Care - this is non-medical care that helps individuals with the basic tasks of everyday life, the preparation of special diets, and the self-administration of medication which does not require the constant attention of medical personnel.  In New Hampshire: this exclusion is not applicable Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including any resulting complications.  In Idaho and New Hampshire: this exclusion is not applicable. Services performed by a family member.  In Idaho: Services performed by an immediate family member.

 In Arizona, New Hampshire and South Dakota: this exclusion does not

apply. Services related to sex or gender change, sterilization, in vitro fertilization, vasec In Idaho: participating in any war or act of war, declared or undeclared, or tomy or reversal of a vasectomy, or tubal ligation. participating or serving in the armed forces or units auxiliary thereto. War  In California, Washington D.C. and Washington: Services related to sterilialso includes participation in a felony, riot, or insurrection. zation, in vitro fertilization, vasectomy or reversal of a vasectomy, or tubal  In New Hampshire: voluntarily participating in war any act of war, declared ligation. or undeclared, or serving in the armed forces or an auxiliary unit thereto.  In Idaho and New Hampshire: this exclusion is not applicable. (We will return the prorated premium for any period not covered by the Elective Abortion - an abortion for any reason other than to preserve the life of certificate when the Insured is in such service.) War also includes voluntary the person upon whom the participation in an insurrection or riot. War does not include acts of terror- abortion is performed. ism.  In Tennessee, or if the pregnancy was the result of rape or incest, or if the  In Oklahoma: War, or any act of war, declared or undeclared, when serving fetus is non-viable. in the military, armed forces, or an auxiliary unit thereto. (We will return  In New Hampshire: this exclusion is not applicable the prorated premium for any period not covered by the certificate when  Dental Services or Treatment. the insured is in such service.) War does not include acts of terrorism. Suicide - committing or attempting to commit suicide, while sane or insane.  In New Hampshire: this exclusion is not applicable.  In Colorado, Missouri, Montana, and Vermont: committing or attempting Cosmetic Surgery, except when due to: to commit suicide, while sane.  Reconstructive surgery, when the service is related to or follows surgery resulting from a covered accidental  In Idaho: committing or attempting to commit suicide, while sane or insane, or intentionally self-inflicting injury.  injury or a covered sickness, or is related to or results from a congenital disease or anomaly of a covered  In Minnesota and Ohio: this exclusion does not apply. Self-Inflicted Injuries - injuring or attempting to injure oneself intentionally.  dependent child.  In Missouri: injuring or attempting to injure oneself intentionally which is  Congenital defects in newborns obviously not an attempted suicide.  In California: Cosmetic surgery, except when due to:  In Colorado and Vermont: injuring or attempting to injure oneself inten Reconstructive surgery, when the service is related to or follows tionally, while sane. surgery resulting from a covered accidental Injury or a covered sick In Idaho and Ohio: this exclusion does not apply ness or when it is performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormali Racing - riding in or driving any motor-driven vehicle in a race, stunt show ties, trauma, infection, tumors, or disease. or speed test in a professional or semi-professional capacity.  Reconstructive surgery, when the service is related to or follows  In Idaho and New Hampshire: this exclusion is not applicable mastectomy or lymph node dissection. This includes surgery to reIllegal Occupation - voluntarily participating in, committing, or attempting to store and achieve symmetry for the patient incidental to a mastectocommit a felony or illegal act or my. activity, or voluntarily working at, or being engaged in, an illegal occupation or job.  In New Hampshire: this exclusion is not applicable In Maryland only: We will not pay benefits for any claim that the appropriate  In California, Ohio, Nebraska and Tennessee: voluntarily participating in, committing, or attempting to commit a felony or voluntarily working at, or regulatory board determines were provided as a result of a prohibited referral as defined in 1-302 of the Health Occupations Article. being engaged in, an illegal occupation or job.  In Connecticut and New Hampshire: voluntarily participating in, committing, or attempting to commit a felony.  In Illinois: committing or attempting to commit a felony or being engaged in an illegal occupation.  In Pennsylvania: committing or attempting to commit a felony, or being engaged in an illegal occupation.  In South Dakota: voluntarily committing a felony.

 In Idaho and Maryland: this exclusion does not apply  Sports - participating in any organized sport in a professional or semi17


AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Accident

PLAY VIDEO

About this Benefit

2/3

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

of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or

usually live paycheck to paycheck.

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 18 ESC Region 20 BC Benefits Website: www.esc20bc.net


A-3 Supplemental Limited Benefit Accident Expense Insurance Burnet ISD

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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

Summary of Benefits* Benefit Description

Level 1 - 1 Unit

Accidental Death - per unit

$5,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $500

Daily Hospital Confinement Benefit

$75 per day

Air and Ground Ambulance Benefit Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

actual charges up to $1,250 $500 $500 $2,500 $5,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

Level 1 - 1 Unit

$2,500 $5,000

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

$10.80

$19.40

$21.20

$29.80

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

DID YOU KNOW?

2/3

*The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

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

American workers 36% ofreport they always or usually live paycheck to paycheck.

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 Burnet ISD Benefits Website: www.mybenefitshub.com/region20

19

APSB-22329(TX)-MGM/FBS Burnet ISD


A-3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3)

No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

(4)

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

(7)

(5) (6)

(8)

(9) (10)

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

The maximum benefit period for this benefit is 30 days per covered accident.

(15)

Accidental Death

(16)

Accidental Death must result within 90 days of the covered accident causing the injury.

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A-3 Supplemental Limited Benefit Accident Expense Insurance If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

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

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | ESC Region 20 Benefits Co-op

20

APSB-22329(TX)-MGM/FBS Burnet ISD

APSB-22329(TX)-MGM/FBS Burnet ISD


A-3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3)

No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

(4)

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

(7)

(5) (6)

(8)

(9) (10)

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

The maximum benefit period for this benefit is 30 days per covered accident.

(15)

Accidental Death

(16)

Accidental Death must result within 90 days of the covered accident causing the injury.

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A-3 Supplemental Limited Benefit Accident Expense Insurance If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

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

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | Burnet ISD

21

APSB-22329(TX)-MGM/FBS Burnet ISD

APSB-22329(TX)-MGM/FBS Burnet ISD


CIGNA

Dental

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 22 ESC Region 20 BC Benefits Website: www.esc20bc.net


Dental PPO - High Plan Benefits Network

Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO

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

$1,500

$1,500

$50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50%*

50%*

50%*

50%

50% $1,000 Dependent children to age 19

50%

Monthly PPO Premiums Tier

Rate

EE Only

$31.72

EE + Spouse

$78.13

EE + Child(ren)

$85.66

Family Coverage

$119.42

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

Class II - Basic Restorative Care Fillings Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia Lifetime Maximum

50% $1,000 Dependent children to age 19

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures

 guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. 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. Dependents/Students up to age 26. 23


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

Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $750

$750

$50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

Based on Maximum Allowable Charge (In-network fee level)

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

60%*

40%*

60%*

40%*

40%*

60%*

40%*

60%*

Monthly PPO Premiums Tier

Rate

EE Only

$15.89

EE + Spouse

$32.29

EE + Child(ren)

$37.13

Family Coverage

$56.68

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

Class II - Basic Restorative Care Fillings Brush Biopsies Oral Surgery – Simple Extractions

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Oral Surgery - all except simple extractions Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia

Not covered

100% of your 100% of your dentist’s Not covered dentist’s usual fees usual fees

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures

 guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. 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. Dependents/Students up to age 26. 24


Dental PPO - High and Low Options Procedure

Exclusions and Limitations

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

None Two per Plan year Two per Plan year 1 per Plan year for people under 19 Various limits per Plan year depending on specific test Bitewings: 2 per Plan year Full mouth: 1 every 36 consecutive months, Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions                         

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

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

25


Dental DHMO Sampling of covered procedures

What You’ll Pay Estimated cost without Cost with Cigna Dental Care dental coverage

Adult cleaning (two per calendar year each at $0) (additional cleanings available at $45 each)

$0

$70–$136 each

Child cleaning (two per calendar year each at $0) (additional cleanings available at $30 each)

$0

$53–$102 each

Periodic oral evaluation Comprehensive oral evaluation

$0 $0

$40–$76 $62–$118

Topical fluoride (two per calendar year each at $0) (additional topical fluoride available at $15 each)

$0

$28–$53

$0 $0 $17 $28 $33 $595

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

$515

$1,042–$2,005

$135 $93 $64 $300 $480

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

$780

$1,097–$2,112

$575

$640–$1,233

X–rays – (bitewings) 2 films X–rays – panoramic film Sealant – per tooth Amalgam filling (silver colored) – 2 surfaces Composite filling (tooth–colored) – 1 surface, Anterior Molar root canal (excluding final restoration) Comprehensive orthodontics – child (up to 19th birthday) – Banding Periodontal (gum) scaling & root planing – 1 quadrant Periodontal (gum) maintenance Removal/extraction of erupted tooth Removal/extraction of impacted tooth Crown – porcelain fused to high noble metal Implant supported retainer for porcelain fused to metal fixed partial denture Occlusal appliance, by report (for treatment of TMJ) Procedure

Limit

Exams

Two per calendar year

X-rays (routine)

Bitewings: 2 per calendar year

X-rays (non-routine)

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

Crowns and inlays

Replacement every 5 years

Bridges

Replacement every 5 years

Dentures and partials

Replacement every 5 years

Relines, rebases

One every 36 months

Adjustments

Four within the first 6 months after installation

Prosthesis over implant

Replacement every 5 years if unserviceable and cannot be repaired

Temporomandibular Joint (TMJ) treatment

One occlusal orthotic device per 24 months

Athletic mouth guard

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

26

Monthly DHMO Premiums Tier

Rate

EE Only

$10.62

EE + Spouse

$20.05

EE + Child(ren)

$22.61

Family Coverage

$35.01

Finding a network dentist is easy. There are several ways to choose your network general dentist:  Find a dentist at Cigna.com. Our online dental directory is updated weekly.  Call 1.800.Cigna24 (1.800.244.6224) to speak with a customer service representative. Our representatives can send you a customized dental directory listing via email.


Dental DHMO Under your plan, you have coverage for hundreds of dental procedures. This overview shows you a small sampling of covered services and what you will pay compared to your estimated cost without coverage. See savings below! Review your plan materials to understand how your plan works. For questions on the plan before enrollment, call 1.800.Cigna24 (1.800.244.6224) and select the “Enrollment Information” prompt.

      

Key plan features  There is a $5 office visit fee associated with your plan.  No deductibles – you don’t have to reach a certain level of out-of-pocket expenses before your insurance kicks in.  No dollar maximums – you don’t have to worry about your coverage running out after your covered expenses reach a certain dollar amount.  Easy to understand plan – the fees you pay your dentist are clearly listed on your Patient Charge Schedule (PCS).  There are no claim forms to fill and no waiting periods for coverage.  The network general dentist you choose will manage your overall dental care.  Covered family members can choose their own network general dentists – near home, work or school.  You don’t need a referral for children under seven to visit a network pediatric dentist. And you don’t need a referral to see a network orthodontist.  There’s no age limit on sealants, which help prevent tooth decay.  Your plan covers certain procedures to help detect oral cancer in its early stages.  24/7 access to the Dental Information Line—this line is staffed by trained professionals who can help you if you have questions about dental treatment and clinical symptoms.

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

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

Or in connection with an injury arising out of, or in the course of, any employment for wage or profit Charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States government or by a state or municipal government if the person had no insurance To the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received

             

         

The charges which the person is not legally required to pay Charges which would not have been made if the person had no insurance Due to injuries which are intentionally self-inflicted Services not listed on the PCS Services provided by a non-network dentist without Cigna Dental’s prior approval (except emergencies, as described in your plan documents) Services related to an injury or illness paid under workers’ compensation, occupational disease or similar laws Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war Services performed primarily for cosmetic reasons unless specifically listed on your PCS General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS Prescription medications Replacement of filled and/or removable appliances (including filled and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect Surgical implant of any type unless specifically listed on your PCS Services considered to be unnecessary or experimental in nature or do not meet commonly accepted dental standards Procedures or appliances for minor tooth guidance or to control harmful habits Services and supplies received from a hospital The completion of crowns, bridges, dentures, or root canal treatment already in progress on the effective date of your Cigna Dental coverage The completion of implant supported prosthesis (including crowns, bridges and dentures) already in progress on the effective date of your Cigna Dental coverage, unless specifically listed on your PCS4 Consultations and/or evaluations associated with services that are not covered Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS Bone grafting and/or guided tissue regeneration when performed in conjunction with an apicoectomy or periradicular surgery Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure Services performed by a prosthodontist Localized delivery of antimicrobial agents when performed alone or in the absence of traditional periodontal therapy Any localized delivery of antimicrobial agent procedures when more than eight (8) of these procedures are reported on the same date of service. Infection control and/or sterilization The recementation of any inlay, onlay, crown, post and core or filled bridge within 180 days of initial placement The recementation of any implant supported prosthesis (including crowns, bridges and dentures) within 180 days of initial placement Services to correct congenital malformations, including the replacement of congenitally missing teeth The replacement of an occlusal guard (night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS Crowns, bridges and/or implant supported prosthesis used solely for splinting Resin bonded retainers and associated pontics 27


SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 28 ESC Region 20 BC Benefits Website: www.esc20bc.net


Vision Benefits

In-Network

Out-of-Network

Monthly Premiums

Exam Covered in full Up to $42 retail (ophthalmologist) Exam (optometrist) Covered in full Up to $37 retail Frames $125 retail allowance Up to $68 retail Contact Lens Fitting Covered in full Not Covered (standard₂) Contact Lens Fitting $50 retail allowance Not Covered (specialty₂) Contact Lenses4 $120 retail allowance Up to $100 retail

EE Only

$6.88

EE + Spouse

$13.66

EE + Child(ren)

$13.38

EE + Family

$20.36

Co-Pays Exam

$10

Materials₁

$25

Contact Lens Fitting (standard & specialty)

$25

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

Covered in full Covered in full Covered in full

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

See description3

Up to $61 retail

Services/Frequency Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 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 copay. 4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Discounts on Covered Materials5 Frames: Lens options: Progressives:

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

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

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

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

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

provider. 5Discounts

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

provider.

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

$80

20% off retail

Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-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. 29


ONEAMERICA

Short Term Disability

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

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 30 ESC Region 20 BC Benefits Website: www.esc20bc.net


Short Term Disability Short Term Disability (STD) Insurance Coverage Eligibility Eligibility Waiting Period

All active, full-time U.S. Employees of the Employer regularly working a minimum of 18.75 hours per week. No waiting period. Benefit Amount

Up to 60% of your weekly covered earnings

Maximum

$1,385 per week

Weekly Benefit

Elimination Period

You must be disabled for 14 days from either accident or sickness. This time period ends automatically on the date you are admitted as an inpatient to a hospital if that occurs before the 14 days are completed.

Important Definitions and Features Definition of Disability

Cost District Paid Benefit for all Qualified Full Time Employees.

Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and/or you are unable to earn 80% or more of your covered earnings from working in your regular occupation. We will require proof of earnings and continued disability.

Covered Earnings Covered earnings means your annual wages or salary, not including bonuses, commissions, other extra compensation and overtime.

Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of covered earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

31


Short Term Disability Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Other income sources that may reduce your benefits under this plan include:  Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.  Benefits payable by a Canadian and/or Quebec provincial pension plan.  Amounts payable under the Railroad Retirement Act.  Amounts payable under any local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.  Employer-paid portion of company retirement plan benefits.  Amounts payable by company sponsored sick leave or salary continuation plan.  Amounts payable by any franchise or group insurance or similar plan.  Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.  Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.  Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

32

Additional Plan Details & Features Earnings While Disabled Benefits will be reduced for any week that benefits plus income from employment exceeds 100% of weekly covered earnings.

Benefit Duration Once you qualify for benefits under this plan, you continue to receive them until the end of the 24 benefit period, or until you no longer qualify for benefits, whichever occurs first.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) or for which a reasonable person would have consulted a physician during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a preexisting condition unless the disability occurs after you have been in active service for a time of 3 consecutive months when you received no medical treatment, care, or services after you have been under this plan for at least 12 months after your most recent effective date of insurance.

Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of indexed earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.


Short Term Disability Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; cosmetic surgery or medically unnecessary surgical procedures; an injury or sickness for which you are entitled to benefits from Workers’ Compensation or occupational disease law; an injury or sickness that is work-related; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

33


ONEAMERICA YOUR BENEFITS PACKAGE

Long Term Disability

PLAY VIDEO

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.

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

34.6 months is the duration of the average disability claim.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 34 ESC Region 20 BC Benefits Website: www.esc20bc.net


Long Term Disability Long Term Disability (LTD) Insurance Coverage Eligibility Eligibility Waiting Period

All active, full-time U.S. Employees of the Employer regularly working a minimum of 18.75 hours per week. No waiting period. Benefit Amount

Up to 60% of your monthly covered earnings

Maximum

$6,000 per month

Monthly Benefit Elimination Period

Benefit Duration

You must be disabled for 180 days before benefits may be payable. Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit period shown below, or until you no longer qualify for benefits, whichever occurs first. Your benefit period begins on the first day after you complete your elimination period. And, should you remain disabled, your benefits continue according to the following schedule, depending on your age at the time you become disabled.

Important Definitions and Features Definition of Disability Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability.

Covered Earnings Covered earnings means your annual wages or salary, not including bonuses, commissions, other extra compensation and overtime.

Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of indexed earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

Cost The cost of this insurance program is paid by you. The cost per $100 of monthly covered earnings are shown below. Costs are subject to change. Under age 30: Age 30 – 34: Age 35 – 39: Age 40 – 44: Age 45 – 49: Age 50 – 54: Age 55 – 59: Age 60+:

$0.081 $0.117 $0.171 $0.342 $0.450 $0.666 $0.882 $1.035

Costs are subject to change. Age at Disability

Age 62 or younger 63 64 65 66 67 68 69+

To age 65 or the Duration of date the 42nd Payments monthly benefit is (months) payable, if later

36 30 24 21 18 15 12

35


Long Term Disability Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Other income sources that may reduce your benefits under this plan include:  Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.  Benefits payable by a Canadian and/or Quebec provincial pension plan.  Amounts payable under the Railroad Retirement Act.  Amounts payable under local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.  Employer-paid portion of company retirement plan benefits.  Amounts payable by company sponsored sick leave or salary continuation plan.  Amounts payable by any franchise or group insurance or similar plan.  Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.  Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.  Amounts payable under any workers’ compensation (including temporary or permanent disability benefits), occupational disease, and unemployment compensation. This includes damages, compromises or settlements paid in place of such benefits, whether or not liability is admitted. Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

36

Additional Plan Details & Features Earnings While Disabled During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability covered earnings. After that, benefits will be reduced by 50% of earnings from employment.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a preexisting condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Limited Benefit Period Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses). Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits. Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits.

Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on


Long Term Disability purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

Family Survivor Benefit If you die while receiving disability benefits, we will pay a survivor benefit based on 100% of the total of your last month’s benefit plus the amount of any disability earnings by which this benefit had been reduced for that month. This plan pays a single lump sum equal to 3 months of benefits. We pay this benefit directly to your lawful spouse, or to your children in equal shares, if there is no lawful spouse. If you have no lawful spouse or children, we pay this benefit to your estate.

37


AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

Breast Cancer is the most commonly diagnosed cancer in women.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 38 ESC Region 20 BC Benefits Website: www.esc20bc.net


GC3 Limited Benefit Group Cancer Indemnity Insurance ESC Region 20 Benefits Co-op Group

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

SUMMARY OF BENEFITS Benefits

Level 1 Plan

Level 2 Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$500 per calendar month of treatment

$1,500 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

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

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

Anesthesia Benefit

25% of the amount paid for covered surgery

25% of the amount paid for covered surgery

Hospital Confinement Benefit

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

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

US Government/Charity Hospital/HMO

$100 per day in lieu of most other benefits

$300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery

$600 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

$150 per confinement

Drugs & Medicine Benefit - Outpatient

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

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

Transportation & Outpatient Lodging Benefit

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

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

Family Member Transportation & Lodging Benefit

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

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

Blood, Plasma & Platelets Benefit

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

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

Bone Marrow/Stem Cell Transplant

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

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

Experimental Treatment Benefit

Pays as any non-experimental benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$30 per day of confinement

$50 per day of confinement

Surgical Prosthesis Benefit

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

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

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

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

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

Hospice Care Benefit

$50 per day, $9,000 lifetime max

$100 per day, $18,000 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

$200 per ground trip

Ambulance Air Benefit

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

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

Extended Care Benefit

$100 per day

$300 per day

Home Health Care Benefit

$100 per day

$300 per day

Second & Third Surgical Opinions

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

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

Waiver of Premium

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

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

Physical/Speech Therapy Benefit

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

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

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

$50; 1 person, per calendar year

Critical Illness Rider: Heart Attack/Stroke

$2,500 lump sum benefit

$2,500 lump sum benefit

$600 up to a max of 30 days per confinement

$600 up to a max of 30 days per confinement

Riders

Optional Benefit Rider Intensive Care Unit Rider

39

APSB-22356(TX) MGM/FBS ESC Region 20 Benefits Co-op


GC3 Limited Benefit Group Cancer Indemnity Insurance Monthly Premium

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$14.80

$17.80

$29.40

$32.40

One-Parent Family

$20.60

$24.80

$40.40

$44.60

Two-Parent Family

$26.40

$32.70

$51.50

$57.80

*Premium and amount of benefits provided vary dependent upon the level selected at time of application.

Eligibility

Diagnostic Testing Benefit Rider

If You are working either under contract to or as a Full-Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us.

Critical Illness Rider

This policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage.

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer. No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward. 40

APSB-22356(TX) MGM/FBS ESC Region 20 Benefits Co-op

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

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

Hospital Intensive Care Unit Rider

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


GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

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

Continuation Rider Continuation

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

Termination of Coverage

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

Termination of Rider Coverage

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

Conversion

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

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

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC-3 Series | Texas | Limited Benefit Group Cancer Indemnity Insurance Policy | (11/14) | ESC Region 20 Benefits Co-op

41

APSB-22356(TX) MGM/FBS ESC Region 20 Benefits Co-op


5STAR

Family Protection Plan

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Experts recommend at least

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 42 ESC Region 20 BC Benefits Website: www.esc20bc.net


Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Term Life Insurance with Terminal Illness Coverage to Age 100 Nearly 85% of Americans say most people need life insurance; unfortunately only 62% have coverage and a staggering 33% say they don’t have enough life insurance, including one-fourth who already have life insurance coverage.** Nobody wants to be a statistic - especially during a period of grief. That’s why 5Star Life Insurance Company developed its FPP policy - to ensure you and your loved ones are covered during a period of loss.

Affordability - With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness - This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability - You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums.

DID YOU KNOW? Protecting your financial well being is easier than you think. It’s like trading in a daily latte for peace of mind.

$4.30 per day to start your morning with a $1.75

gourmet coffee OR per day to enrich your employee benefits package

It’s less expensive than you think.

Family Protection - Individual policies can be purchased on the employee, their spouse, children and grandchildren (ages 14 days to age 23). Quality of Life Benefit - Following a diagnosis of either a chronic illness or cognitive impairment, this rider accelerates a portion of the death benefit on a monthly basis – 4%; up to 75% of your benefit, and payable directly to you on a tax favored basis for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or  Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision. Convenience - Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On - Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the twoyear contestability period and/or under investigation. This product also contains no war or terrorism exclusions. * Life * Life insurance product underwritten by 5Star Life insurance Company (a Baton Rouge, Louisiana company) with an administrative office at 909 N. Washington Street, Alexandria, VA 22314

43


Individual Life MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

$10,000 $7.56 $7.59 $7.65 $7.74 $7.88 $8.07 $8.27 $8.50 $8.73 $9.01 $9.30 $9.64 $10.02 $10.41 $10.85 $11.31 $11.83 $12.41 $13.00 $13.63 $14.27

$20,000 $10.78 $10.83 $10.97 $11.15 $11.43 $11.80 $12.20 $12.65 $13.11 $13.67 $14.27 $14.95 $15.70 $16.48 $17.35 $18.29 $19.33 $20.48 $21.66 $22.91 $24.22

$30,000 $14.01 $14.09 $14.28 $14.56 $14.99 $15.53 $16.14 $16.81 $17.51 $18.34 $19.23 $20.26 $21.39 $22.56 $23.86 $25.26 $26.83 $28.56 $30.34 $32.21 $34.16

Employee Coverage Amounts $40,000 $50,000 $75,000 $17.24 $20.46 $28.53 $17.33 $20.59 $28.71 $17.60 $20.92 $29.21 $17.96 $21.38 $29.90 $18.54 $22.09 $30.96 $19.27 $23.00 $32.34 $20.06 $24.00 $33.84 $20.97 $25.12 $35.52 $21.90 $26.29 $37.27 $23.00 $27.67 $39.33 $24.20 $29.17 $41.59 $25.57 $30.88 $44.15 $27.07 $32.76 $46.96 $28.64 $34.71 $49.89 $30.37 $36.87 $53.15 $32.23 $39.21 $56.65 $34.33 $41.83 $60.58 $36.63 $44.71 $64.90 $39.00 $47.67 $69.33 $41.50 $50.79 $74.02 $44.10 $54.05 $78.90

46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

$14.97 $15.70 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.26 $25.94 $27.66 $29.42 $31.23 $33.12 $35.08 $37.12 $39.31 $41.68 $44.34

$25.60 $27.05 $28.51 $30.10 $31.82 $33.75 $35.98 $38.46 $41.25 $44.20 $47.53 $50.98 $54.50 $58.12 $61.90 $65.82 $69.91 $74.29 $79.04 $84.33

$36.24 $38.41 $40.61 $42.98 $45.56 $48.46 $51.81 $55.54 $59.71 $64.13 $69.14 $74.31 $79.58 $85.01 $90.69 $96.56 $102.71 $109.26 $116.38 $124.34

$46.87 $49.77 $52.70 $55.87 $59.30 $63.17 $67.63 $72.60 $78.17 $84.06 $90.73 $97.63 $104.67 $111.90 $119.46 $127.30 $135.50 $144.23 $153.73 $164.33

Age on Eff. Date

44

$57.51 $61.13 $64.79 $68.75 $73.04 $77.88 $83.46 $89.67 $96.63 $104.00 $112.34 $120.96 $129.75 $138.79 $148.25 $158.04 $168.29 $179.21 $191.09 $204.34

$84.09 $89.52 $95.03 $100.96 $107.39 $114.65 $123.02 $132.33 $142.77 $153.83 $166.33 $179.27 $192.46 $206.02 $220.21 $234.90 $250.27 $266.65 $284.46 $304.33

$100,000 $36.59 $36.83 $37.50 $38.41 $39.84 $41.67 $43.66 $45.92 $48.25 $51.00 $54.00 $57.42 $61.17 $65.09 $69.42 $74.08 $79.33 $85.08 $91.00 $97.25 $103.75

$125,000 $44.65 $44.96 $45.80 $46.94 $48.71 $51.01 $53.50 $56.31 $59.23 $62.67 $66.42 $70.69 $75.37 $80.27 $85.68 $91.52 $98.08 $105.27 $112.67 $120.48 $128.60

$150,000 $52.71 $53.09 $54.08 $55.46 $57.59 $60.33 $63.34 $66.71 $70.21 $74.34 $78.83 $83.96 $89.59 $95.46 $101.96 $108.96 $116.83 $125.46 $134.34 $143.71 $153.46

$110.67 $117.92 $125.25 $133.17 $141.75 $151.42 $162.58 $175.00 $188.92 $203.66 $220.33 $237.58 $255.17 $273.25 $292.16 $311.75 $332.25 $354.08 $377.83 $404.33

$137.25 $146.32 $155.48 $165.37 $176.10 $188.19 $202.15 $217.67 $235.07 $253.50 $274.34 $295.89 $317.87 $340.48 $364.13 $388.60 $414.23 $441.52 $471.21 $504.34

$163.84 $174.71 $185.71 $197.58 $210.46 $224.96 $241.71 $260.34 $281.21 $303.33 $328.34 $354.21 $380.58 $407.71 $436.09 $465.46 $496.21 $528.96 $564.58 $604.34


Individual Life MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Age on Eff. Date 66* 67* 68* 69* 70*

$10,000 $44.93 $48.25 $52.03 $56.33 $61.17

$20,000 $85.52 $92.17 $99.73 $108.32 $118.00

$30,000 $126.11 $136.08 $147.43 $160.31 $174.83

Employee Coverage Amounts $40,000 $50,000 $75,000 $166.70 $207.29 $308.77 $180.00 $223.92 $333.71 $195.13 $242.83 $362.08 $212.30 $264.29 $394.27 $231.67 $288.50 $430.58

$100,000 $410.25 $443.50 $481.33 $524.25 $572.67

$125,000 $511.73 $553.29 $600.58 $654.23 $714.75

$150,000 $613.21 $663.08 $719.83 $784.21 $856.83

*Quality of Life not available ages 66 - 70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on effective date: age 14 days to 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

45


ONEAMERICA YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

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.

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 46 ESC Region 20 BC Benefits Website: www.esc20bc.net


Basic & Voluntary Term Life Basic Term Life Insurance Coverage (paid by your employer) Eligibility - Active, full-time Employees of the Employer regularly working a minimum of 20 hours per week. Benefit Amount and Maximum based on the option chosen by your employer:  Option I: $5,000  Option II: $10,000  Option III: $15,000  Option IV: $20,000  Option V: $50,000 Benefit Reduction Schedule – Benefits will reduce to 65% at age 65, 50% at age 70, 25% at age 75.

Voluntary Term Life Insurance Coverage (paid by you) Employee – If you are an active, full-time employee and work at least 18.75 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service.    

Amount –1 to 7 X Annual Compensation Guaranteed Coverage Amount – $200,000 Maximum – $500,000 Benefit Reduction Schedule –Providing you are still employed, your benefits will reduce to 65% at age 65, 50% at age 70, 25% at age 75.

Your Spouse* — terms at age 70 - is eligible provided that you apply for and are approved for coverage for yourself.   

Benefit Amount – Units of $10,000 Guaranteed Coverage Amount - $50,000 Maximum – $500,000, not to exceed 100% of the employee’s coverage amount

Your Unmarried, Dependent Children — Under age 26 , as long as you apply for and are approved for coverage for yourself.  

Benefit Amount – $10,000 Maximum – $10,000

No one may be covered more than once under this plan.

Guaranteed Coverage for Voluntary Term Life Insurance Coverage Guaranteed Coverage Amount is the amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed Coverage is only available during Initial Enrollment and other times as approved. If you apply for coverage that is above the Guaranteed Coverage Amount, or if you are applying for coverage after 31 days after you become eligible, you must fill out a Medical Evidence of Insurability form. All dependent child benefits are guaranteed issue.

Other Coverage Features Accelerated Death Benefit — Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 75% of the Term Life Insurance coverage amount inforce or $250,000, whichever is less, to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer’s plan. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance

47


Basic & Voluntary Term Life company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and have insured your spouse or children, their premium is also waived.

brochure which may be requested as needed. Premiums may change at this time. Portability This plan allows you to continue all of your voluntary coverage if you leave your employer. Premiums may change at this time. Just pay your premiums directly to the insurance company. Coverage may be continued for you and your spouse until age 70. Coverage may also be continued for your children.

Conversion If group life insurance coverage is reduced or ends for any reason except nonpayment of premiums, you can convert to an individual policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Family members may convert their coverage as well. Converted policies are subject to certain benefits and limits as outlined in the conversion

Exclusions Voluntary life insurance will not be paid if loss of life is the result of suicide that occurs within the first two years of coverage.

How Much Your Coverage Will Cost Per Month (costs are subject to change)

Age

Employee Cost Per $10,000

Spouse Cost Per $10,000

Age

Employee Cost Per $10,000

Spouse Cost Per $10,000

<29

$0.50

$0.50

60-64

$5.90

$5.90

30-34

$0.70

$0.70

65-69

$8.26

$8.26

35-39

$0.80

$0.80

70-74

$10.30

40-44

$1.00

$1.00

75-79

$14.70

45-49

$1.40

$1.40

80+

$14.70

50-54

$2.40

$2.40

55-59

$3.90

$3.90

Benefit

Voluntary Child per $10,000 of Coverage Elected

Cost Calculation Example Age Example

Yours

48

33

Monthly Cost per $10,000 .70

Benefit X X

100,000

/ /

10,000

=

10,000

=

Monthly Cost $7.00

Premium Cost

$1.80


Voluntary Personal Accident Basic Personal Accident Insurance Coverage (paid by your employer)

coverage. We will refund premium if you do not notify us of this and it is determined at the time of a claim that premium has been overpaid.

Employee - If you are an active, full-time employee and work at least 18.75 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service

How Much Your Coverage Will Cost Per Month

Benefit Amount and Maximum based on the option chosen by your employer:  Option I: $5,000  Option II: $10,000  Option III: $15,000  Option IV: $20,000  Option V: $50,000 Benefit Reduction Schedule – Benefits will reduce to 65% at age 65, 50% at age 70, 25% at age 75.

Voluntary Personal Accident Insurance Coverage (paid by you) Employee - If you are an active, full-time employee and work at least 18.75 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service   

Benefit Amount – Units of $10,000 Maximum – $500,000 Benefit Reduction Schedule – Providing you are still employed, your benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, 15% at age 85+.

The cost of the voluntary insurance is paid by you. Indicate your choice, or your decision not to elect coverage, on your enrollment form. The monthly cost per $1,000 of coverage is $0.025 for Employee, $0.04 for Family. Costs are subject to change.

A Valuable Combination of Benefits To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below.

If, within 365 days of a covered accident, bodily injuries result in:  Loss of life  Total paralysis of upper and

lower limbs, or  Loss of any combination of two:

hands, feet or eyesight, or

100%

 Loss of speech and hearing in

both ears  Total paralysis of both lower or 

Family Plan Benefit Based on Family members at time of accident:  50% for spouse if no children  50% for spouse if eligible children  10% for children if eligible spouse  10% for children if no spouse

We will pay this % of the benefit amount: 100%

  

Spouse maximum principle sum: - $250,000 Child maximum principle sum: - $50,000

No one may be covered more than once under this plan.

You may need to request changes to your existing coverage if, in the future, you no longer have dependents who qualify for

upper limbs Total paralysis of upper and lower limbs on one side of the body, or Loss of hand, foot or sight in one eye, or Loss of speech or loss of hearing in both ears, or Severance and Reattachment of one hand or foot Total paralysis of one upper or lower limb, or Loss of all four fingers of the same hand, or Loss of thumb and index finger of the same hand Loss of all toes of the same foot

75%

50%

25%

20%

49


Voluntary Personal Accident What is Not Covered Self-inflicted injuries or suicide while sane or insane; commission or attempt to commit a felony or an assault; any act of war, declared or undeclared; any active participation in a riot, insurrection or terrorist act; bungee jumping; parachuting; skydiving; parasailing; hanggliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew.

When Your Coverage Begins and Ends Coverage becomes effective on the later of the programâ&#x20AC;&#x2122;s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid.

50

Additional Benefits of Personal Accident Insurance For Wearing a Seatbelt & Protection by an Airbag Additional 10% benefit but not more than $25,000 if the covered person dies in an automobile accident while wearing a seatbelt or approved child restraint. We will increase the benefit by an additional 5% but not more than $5,000 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag).

For Comas 1% of full benefit amount, for up to 11 months, if you, your spouse, or your children are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid.

For Exposure & Disappearance Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident. If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident.

For Furthering Education If you die in a covered accident, we will pay an extra benefit for each insured child under age 25 who enrolls in a school of higher learning within one year of your death.


Voluntary Personal Accident We will increase your benefit by 3% or $3,000, whichever is less, for each qualifying child, each year for 4 consecutive years as long as your child continues his/her education. If there is no qualifying child, we will pay an additional $1,000 to your beneficiary.

For Child Care Expenses If you die as a result of a covered accident, we will pay a benefit for a surviving child under 13 who is enrolled in a licensed child care center at the time of the accident or within 90 days afterwards. This benefit is 3% of your benefit amount per year, but not more than $3,000 per year for 5 years or until the child turns 13, whichever occurs first, for each covered child

For Training for Your Spouse If you die from a covered accident, your spouse will receive educational reimbursement if he or she enrolls, within 3 years of your death, in an accredited school to gain skills needed for employment. We will pay the actual cost of the education or training program to 3% of your benefit amount, not exceeding $5,000.

51


AFLAC

Critical Illness

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

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 52 ESC Region 20 BC Benefits Website: www.esc20bc.net


Critical Illness Features and Plan Provisions Benefit Amounts Spouse Coverage Guaranteed Issue Amounts

Requirement for Group Billing Payment Method Pre-existing Condition Exclusion Waiting Period Benefit Reductions

Payroll Deducted

Rate Guarantee Portability/Continuation Rate Type Eligibility

Waiver of Premium Separation Period - Additional Diagnosis/ Reoccurrence

Successor Insured Issue Ages

Base Benefits

Skin Cancer Health Screening Benefit

Additional Base Benefits Optional Benefits Rider Childhood Conditions Rider

Coronary Artery Bypass Surgery, Non-Invasive Cancer

25%

Heart Attack, Stroke, Kidney Failure (End-Stage Renal Failure), Major 100% Organ Transplant, Bone Marrow Transplant (Stem Cell Transplant), Sudden Cardiac Arrest, Cancer (Internal or Invasive) Skin Cancer $250 per calendar year Payable for health screening tests performed as the result of preventive care. Not payable for dependent children. $50 per calendar year Coma, Severe Burns, Paralysis, Loss of Sight, Loss of Speech, Loss of Hearing Advanced Alzheimerâ&#x20AC;&#x2122;s Disease, Advanced Parkinson's Disease

100%

Benign Brain Tumor Cystic Fibrosis, Cerebral Palsy, Cleft Lip or Cleft Palate, Down Syndrome, Phenylalanine Hydroxylase Deficiency Disease (PKU), Spina Bifida , Type I Diabetes

100%

25%

50% of employee benefit

Benefits will be based on the face amount in effect on the critical illness date of diagnosis. Please request a sample policy for full benefit descriptions and 53 definitions.


Critical Illness Group Critical Illness Benefits

Reoccurrence+

(Applies to Base Benefits, Additional Critical Illnesses, Optional Benefits Rider, Progressive Diseases Rider, and Specified Diseases Rider)

Once benefits have been paid for a covered critical illness, benefits are payable for that same critical illness when the date of diagnosis is separated by at least 6 consecutive months and the new critical illness is not caused or contributed to by a critical illness for which benefits have been paid.

Where applicable, covered conditions must be caused by underlying diseases as defined in the plan.

Initial Diagnosis+ An insured may receive up to 100% of his face amount upon the diagnosis of a covered critical illness.

Additional Diagnosis+ Once benefits have been paid for a covered critical illness, we will pay benefits for each different critical illness when the date of diagnosis is separated by at least 6 consecutive months and the new critical illness is not caused or contributed to by a critical illness for which benefits have been paid.

+ If the claim is for a cancer diagnosis, the insured must be treatment-free from cancer for at least 12 months and must be in complete remission before the date of a subsequent cancer diagnosis.

ESC Region 20 Benefits Cooperative - Monthly (12pp/yr) Rates UNITOBACCO - Employee Issue Age

$5,000

$10,000

$15,000

$20,000

18-29

$3.90

$6.28

$8.65

$11.03

30-39

$5.41

$9.30

$13.20

$17.09

40-49

$8.97

$16.42

$23.87

$31.32

50-59

$15.99

$30.46

$44.93

$59.41

60+

$28.73

$55.93

$83.14

$110.35

ESC Region 20 Benefits Cooperative - Monthly (12pp/yr) Rates UNITOBACCO - Spouse Issue Age

$5,000

$10,000

$15,000

$20,000

18-29

$3.62

$5.73

$7.83

$9.94

30-39

$5.14

$8.76

$12.38

$16.00

40-49

$8.70

$15.87

$23.05

$30.23

50-59

$15.72

$29.92

$44.12

$58.31

60+

$28.45

$55.39

$82.32

$109.25

54


Critical Illness

55


HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 56 ESC Region 20 BC Benefits Website: www.esc20bc.net


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 ESC Region 20 BC website at www.esc20bc.net

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.

2018 Annual HSA Contribution Limits Individual: $3,450 Family: $6,900 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) 57


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

How an HSA works: 

 

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

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

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2. 58

2018 Annual HSA Contribution Limits Individual = $3,450 Family = $6,900

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

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

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


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

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

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

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

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 59


NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

Unlimited General Purpose 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. Limited Purpose FSA (HSA Compatible) The funds in the limited purpose FSA can be used for dental and vision expenses only.

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 60 ESC Region 20 BC Benefits Website: www.esc20bc.net


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 throw away your cards, there is a $5.00 fee to replace them.

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 ESC Region 20 BC benefit website: www.esc20bc.net

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

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

FSA Annual Contribution Max:

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

$2,650

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claims FAQs 61


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.esc20bc.net

62

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

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.esc20bc.net and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

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


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

Get Your Money 1. 2. 3. 4.

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

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

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

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

63


MASA YOUR BENEFITS PACKAGE

Medical Transport

About this Benefit Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter.

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

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 64 ESC Region 20 BC Benefits Website: www.esc20bc.net


Medical Transport MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network, which means you are covered anywhere.

THE TRUTH... Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or critical care transport. The reality is that a majority of Americans are only partially covered for these high costs. Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill. BENEFIT You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill. MASA provides medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short.

EMERGENT $9/mo. (30% off)

Emergency Helicopter Transport

Emergency Ground Ambulance Transport

“All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015

MASA MTS for Employees Ensures...      

NO health questions NO age limits NO claim forms NO deductibles NO provider network limitations NO dollar limits on emergency transport costs

What is Covered?  

Emergency Helicopter Transport Emergency Ground Ambulance Transport

65


ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered. An identity is stolen every 2 seconds, and takes over

300 hours

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 66 ESC Region 20 BC Benefits Website: www.esc20bc.net


Identity Theft Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

Identity theft devastates its victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.

Repairing the damage caused by identity theft is frustrating and time consuming.

ID Watchdog Monthly Rates 1B

$7.95

PLATINUM

$14.95

ID Watchdog Services Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee

The average victim spends 330 hours repairing the damage from identity theftâ&#x20AC;&#x201D;the equivalent of working a full-time job for more than 2 months.

The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.

Whoâ&#x20AC;&#x2122;s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

67


WWW.ESC20BC.NET 68

2018 Benefit Guide ESC Region 20- Nixon Smiley ISD  

2018 Benefit Guide ESC Region 20- Nixon Smiley ISD