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BURNET CISD

BENEFIT GUIDE EFFECTIVE: 09/01/2018 - 8/31/2019 WWW.MYBENEFITSHUB.COM/BURNETCISD

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Table of Contents Benefit Contact Information About This Benefits Summary Quick Reference Rates 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. HSA vs. FSA Comparison TRS-ActiveCare TRS-FirstCare Scott & White HMO NBS Flexible Spending Account (FSA) HSA Bank Health Savings Account (HSA) MDLIVE Telehealth AFLAC Hospital Indemnity Plan APL Accident Cigna Dental Superior Vision OneAmerica Disability APL Cancer Plan OneAmerica Life and AD&D 5Star Individual Life MASA Medical Transport ID Watchdog Identity Theft NBS 403(b) Plan 2

3 4 5 6-7 8-13 8 9 10 11 12 13 14-15 16-17 18-19 20-21 22-23 24-25 26-29 30-33 34-37 38-39 40-43 44-47 48-49 50-53 54-55 56-57 58-61

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

PG. 6 SUMMARY PAGES

PG. 14 YOUR BENEFITS


Benefit Contact Information BURNET CISD HR

BURNET CISD BENEFITS

HOSPITAL INDEMNITY PLAN

Michele Gilmore Director of Human Resources (512) 756-2124 mgilmore@burnet.txed.net

Michele Darling Benefits Coordinator (512) 756-2124 mdarling@burnet.txed.net

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

TRS ACTIVECARE MEDICAL

DISABILITY

IDENTITY THEFT

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

OneAmerica 800-553-5318 www.oneamerica.com

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

TRS HMO MEDICAL

LIFE AND AD&D

FLEXIBLE SPENDING ACCOUNT

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

OneAmerica 800-553-5318 www.oneamerica.com

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

TRS FIRSTCARE MEDICAL

INDIVIDUAL LIFE

MASA MEDICAL TRANSPORT

FirstCare (800) 884-4901 www.firscare.com/trs

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

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

TELEHEALTH

CANCER

HEALTH SAVINGS ACCOUNT

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

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

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

DENTAL

ACCIDENT

403(B) / 457 PLAN

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

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

National Benefit Services (512) 756-2124 www.nbsbenefits.com

VISION

ESC REGION 20 BC BENEFITS

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

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/burnetcisd 3


About this Benefits Summary

This Benefits Summary provides highlights of your Burnet CISD employee benefits program. It is not a legal document and will not guarantee benefits through Burnet CISD. All benefit plans are governed by master policies, contracts and plan documents.

Any discrepancies between information provided through this summary and the actual terms of the policies, contracts and plan documents are governed by the terms of these policies, contracts and plan documents. Detailed benefit plan documents will be available on the Burnet CISD benefits website:

@ www.mybenefitshub.com/burnetcisd

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Quick Reference Rates Medical—TRS Monthly Premiums BCISD contributes $364.00 towards the full premium Tier

TRS ActiveCare 1HD

TRS ActiveCare Select

Closed to new participants

EE Only

FREE

$165.00

$407.00

$203.36

$159.04

EE + SP

$660.00

$952.00

$1,480.00

$978.40

$973.92

EE+ Child(ren)

$326.00

$501.00

$788.00

$533.06

$474.76

EE + Family

$999.00

$1,293.00

$1,819.00

$1,134.56

$1,010.36

TRS ActiveCare 2

Scott & White FIRSTCARE (HMO) Health Plan (HMO)

Dental—Cigna Monthly Premiums by Plan

Vision—Superior Monthly Premiums

BCISD Contributes $24.78 towards the full premium

BCISD Contributes $6.04 towards the full premium

Tier

Low Plan

High Plan

EE Only

No Cost

EE Only

FREE

FREE

EE + SP

$5.96

EE + SP

$7.51

$38.46

EE + Child(ren)

$5.71

EE + Child(ren)

$12.35

$43.27

EE + Family

$11.84

EE + Family

$31.90

$70.14

Telehealth—MDLIVE Monthly Premium—BCISD pays for this benefit Individual and Family

No Cost

BCISD provides a $30,000 life insurance policy to all employees at FREE! You will also receive a Debit Card with your Healthcare Reimbursement plan at FREE! Up to 2% match provided by BCISD for 403(b) contribution (50% match program through Fidelity) 5


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

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Text “FBS ESC20” to 313131 OR SCAN


How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/burnetcisd

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.

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

Benefit elections will become affective 9/1/2018. Elections requiring evidence of insurability, such as Life Insurance, may have a later effective 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 and Low PPO plans.

Short Term and Long Term Disability will be changing from Cigna to One America/ AUL. The current plan designs and rates will stay the same. All new or increases in coverage are subject to pre-existing condition exclusions.

   

New - Hospital Indemnity insurance is designed to supplement your medical coverage, easing the financial impacts 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 Options.

Changing! 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.

Login and complete your benefit enrollment from 7/09/2018—8/17/2018. Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to a representative Monday-Thursday 8am-5:30pm & Friday 8am-3pm . Update your profile information: home address, phone numbers, email. Update dependent social security numbers and student status for college aged children.

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SUMMARY PAGES

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

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

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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

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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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

Changes, additions or drops may be made only during the

Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

burnetcisd. Click on the benefit plan you need information on

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

For benefit summaries and claim forms, go to your school

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

(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.

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 15 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within Burnet CISD or as both

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

employees and dependents.

work concurrent with the plan effective date. For example, if your 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

Individual Life

5Star

Through 22

Hospital Indemnity Plan

AFLAC

Through 25

Telehealth

MDLIVE

Through 25

Vision

Superior Vision

Through 25

Voluntary Life and AD&D

OneAmerica

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. 11


Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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(including diagnostic and/or consultation services).


SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

$1,300 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. 22

FLIP TO FOR FSA INFORMATION

PG. 20

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2018 – 2019 TRS-ActiveCare Plan Highlights Effective September 1, 2018 through August 31, 2019 | In-Network Level of Benefits1

Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays Preventive Care See below for examples Teladoc® Physician Services

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Participant pays Freestanding Emergency Room Participant pays

$500 copay per visit plus 20% after deductible

$500 copay per visit plus 20% after deductible

$500 copay per visit plus 20% after deductible

Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Participant pays Annual Hearing Examination Participant pays Preventive Care Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smoking cessation counseling– 8 visits per 12 months

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• Well-child care – unlimited up to age 12 • Colonoscopy – 1 every 10 years age 50 and over •Healthydiet/obesity counseling– unlimited to

• Well woman exam & pap smear – annually age 18 and over • Prostatecancerscreening–1 per year age 50 and over • Breastfeeding support – 6 lactation counseling visits


Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after deductible, except for certain generic preventive drugs that are covered at 100%.2 20% coinsurance after deductible 50% coinsurance after deductible Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)5 20% coinsurance after deductible

$20 for a 1- to 31-day supply $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply3 $40 for a 1- to 31-day supply3 50% coinsurance for a 1- to 31-day supply3 50% coinsurance for a 1- to 31-day supply (Min. $654; Max. $130)3

$45 for a 60- to 90-day supply

$45 for a 60- to 90-day supply

$105 for a 60- to 90-day supply3 $105 for a 60- to 90-day supply3 3 50% coinsurance for a 60- to 90-day supply 50% coinsurance for a 60- to 90-day supply3 (min. $1804 , max $360)3 Specialty Medications 20% coinsurance after deductible 20% coinsurance 20% coinsurance (up to a 31-day supply) (min. $2004 , max $900) Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) 20% coinsurance after deductible 50% coinsurance after deductible

Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand

20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible

$35 for a 1- to 31-day supply $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply $60 for a 1- to 31-day supply 50% coinsurance for a 1- to 31-day supply3

What is a maintenance medication? Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply. A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. 2 For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 - individual, $5,500 - family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.

Full monthly premium*

Premium with min. state/ district contribution**

$367

+Spouse +Children +Family

Individual

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$142

$540

$1,035

$810

$701

$476

$1,374

$1,149

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$315

$782

$557

$1,327

$1,102

$1,855

$1,630

$876

$651

$1,163

$938

$1,668

$1,443

$2,194

$1,969

Your Monthly Premium***

* If you are not eligible for the state/district subsidy, you will pay the full monthly premium. Please contact your Benefits Administrator for your monthly premium. ** The premium after state, $75 and district, $150 contribution is the maximum you pay per month. Ask your Benefits Administrator for your monthly cost. (This is the amount you will owe each month after all available subsidies are applied to your premium.) *** Completed by your benefits administrator. The state/district contribution may be greater than $225. 15


2018-2019 TRS-FirstCare Plan Highlights Plan Summary 2018 -2019 Medical Plan Year Deductible Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) Annual Maximum

$750 Individual; $2,250 Family $7,350 Individual: $14,700 Family Unlimited

Primary Care Provider (PCP) Office Visit  Includes routine lab/X-ray services, injectables, and supplies  Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$20 copayment

PCP Office Visit-Dependents, through age 19

$0 copayment

Specialist Office Visit  Includes routine lab/X-ray services  Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$60 copayment

Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening

No copayment

Surgical Procedures Performed in the Physician's Office

25% copayment1

Minor Emergency/Urgency Care Visit

$75 copayment

Emergency Room

$500 copayment1

Ambulance Air/Ground

25% copayment1

Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility, behavioral health (mental health/chemical dependency)

25% copayment1

Outpatient Services Facility charges, physician services, surgical procedures, observation unit

25% copayment1

MRI, CT Scan, PET Scan (Facility/Physician)

$250 copayment1

Diagnostic Tests Sleep study; Stress test; EKG; Ultrasound; Cardiac imaging; Genetic testing; Non-preventive Colonoscopy (Facility/Physician)

25% copayment1

Home Health Care Limited to 60 visits per plan year

25% copayment1

Hospice Care

25% copayment1

Skilled Nursing Facility Limited to 30 days per plan year

25% copayment1

Accidental Dental Care

25% copayment1

Prosthetics

25% copayment1

Orthotics

25% copayment1

Spinal Manipulation Limited to 10 visits per year

25% copayment1

Durable Medical Equipment

25% copayment1

All Other Covered Services

25% copayment1

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Prescription Drug Plan Year Deductible

$100 Individual: $300 Family

Annual Maximum

Unlimited

Participating Retail Pharmacy  Select Generic/ACA (Tier 1) deductible waived  Preferred Generic (Tier 2) deductible waived  Preferred Brand/Non-Preferred Generic (Tier 3)  Non-Preferred Brand/Non-Preferred Generic (Tier 4)  Specialty/Injectables (Tier 5)

Standard Drugs/30-day supply $0 per prescription $15 per prescription $40 per prescription2 $100 per prescription2 20% per prescription2

Participating Mail Order Pharmacy  Select Generic/ACA (Tier 1) deductible waived  Preferred Generic (Tier 2) deductible waived  Preferred Brand/Non-Preferred Generic (Tier 3)  Non-Preferred Brand/Non-Preferred Generic (Tier 4)  Specialty/Injectables (Tier 5)

Maintenance Drugs/90-day supply $0 per prescription $45 per prescription $120 per prescription2 $300 per prescription2 20% per prescription2

1

Subject to medical deductible

2

Subject to prescription drug deductible

Gross Monthly Cost for Coverage Effective September 1, 2018 - August 31, 2019 Coverage Category Employee only Employee and spouse Employee and child(ren) Employee and family

Total Cost - Active* $534.04 $1,348.92 $849.76 $1,385.36

*District and state fund are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.

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2018-2019 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services

Copay

Preventive Services

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions

Copay

Annual Deductible

$1,000 Individual/ $3,000 Family

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

Lifetime Paid Benefit Maximum

Outpatient Services

$7,000 Individual/ $14,000 Family (includes combined Medical and RX copays, deductibles and coinsurance)

None

Copay $15 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$70 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections

No Charge 20% after deductible

Outpatient Surgery

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

Maternity Care

Copay

Prenatal Care

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

Inpatient Delivery

Inpatient Services

Copay

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

Diagnostic & Therapeutic Services Physical and Speech Therapy Manipulative Therapy

5

Equipment and Supplies Preferred Diabetic Supplies and Equipment Non-Preferred Diabetic Supplies and Equipment Durable Medical Equipment/ Prosthetics 18

$150 per day4 and 20% of charges after deductible

Copay $70 copay 20% without office visit $40 plus 20% with office visit

Copay $5/$12.50 copay; no deductible 30% after Rx deductible 20% after deductible


2018-2019 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services

Copay

Home Health Care Visit

$70 co-pay

Worldwide Emergency Care

Copay

Nurse Advice Line

1-877-505-7947

Online Services

No Charge — go to http://trs.swhp.org

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay plus 20% of charges after deductible

Emergency Room6

$250 copay plus 20% of charges after deductible

Urgent Care Facility

$50 copay per visit; deductible does not apply

Prescription Drugs (Group Value Formulary)

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$150

Does not apply to preferred generic drugs

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

Maintenance Quantity Retail Quantity (Up to a 30-day supply)

BSW Pharmacies Only, including Mail Order (Up to a 90-day supply)

$5 copay

$12.50 copay

Preferred Brand

30% after Rx deductible

30% after Rx deductible

Non-preferred

50% after Rx deductible

50% after Rx deductible

Preferred Generic

Online Refills Mail Order

Specialty Medications

http://trs.swhp.org 1-817-388-3090

Copay Tier 1: 15% after Rx deductible

(Up to a 30-day supply)

Tier 2: 15% after Rx deductible Tier 3: 25% after Rx deductible

1

Including all services billed with office visit Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after deductible 5 35 max visit per year 6 Copay waived if admitted within 24 hours 2

The SWHP MOMS Program provides you with professional staff who are notified of the delivery of your baby. These licensed professionals will contact you after you return home and help you with everything from the general well-being of both you and your baby, to breast/bottle feeding, to information on how to add your baby to your health plan.

19


NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

FLIP TO‌ PG. 13 FOR HSA VS. FSA COMPARISON

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 20 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


FSA (Flexible Spending Account) A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. Your contributions are deducted from your pay before taxes are withheld. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend. 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.

NBS Prepaid MasterCard® Debit Card

NBS Flex 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 then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file paper claims or enroll in continual reimbursement.

For a list of sample expenses, please refer to the Burnet CISD benefit website: www.mybenefitshub.com/burnetcisd

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

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

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 in mid-September. NBS debit cards are good for 4 years.

FSA Annual Contribution Max: $2,650

Dependent Care Annual Max: $5,000 ($2,500 for married individuals filing separately)

Account Information: Participant Account Web Access: www.nationalbenefitservices.com     

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

Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 7 am to 4 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 (888) 353-9125. For immediate access to your account information at any time, log on to the NBS website www.NBSbenefits.com.

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 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 and contributions are use-it-or- lose-it. Remember to retain all your receipts.

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you loose your card or are waiting to received one you can visit www.mybenefitshub.com/ burnetcisd and complete the “Claim Form” to send to NBS.

When Will I Receive My Flex Card? Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September.

21


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 22 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


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. Monthly Fee: Your account will be charged a monthly fee of $1.75. 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  Surgery medical expenses are always tax-free.  Braces

Examples of Qualified Medical Expenses

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. Additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds 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.

   

Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the Burnet CISD website at www.mybenefitshub.com/burnetcisd

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

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)

23


MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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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 24 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


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

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

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

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

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

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

How much does it cost? $0 - BCISD covers this benefit for FREE Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

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

Scan with your smartphone to get the app.

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

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for 25 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

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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 26 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 Guaranteed Issue Amounts enrollment 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.

27


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

28

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 semi29


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 30 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

31

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

32

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

33

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 34 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


Dental PPO - High Option Benefits Network

Cigna Dental PPO - High Option 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

$0.00

EE + Spouse

$38.46

EE + Child(ren)

$43.27

Family Coverage

$70.14

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. 35


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

Cigna Dental PPO - Low Option 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 (Innetwork 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

$0.00

EE + Spouse

$7.51

EE + Child(ren)

$12.35

Family Coverage

$31.90

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. 36


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

37


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 38 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


Vision Benefits Exam (ophthalmologist) Exam (optometrist) Frames Contact Lens Fitting (standard₂) Contact Lens Fitting (specialty₂) Contact Lenses4

In-Network

Out-of-Network

Monthly Premiums

Covered in full

Up to $42 retail

Covered in full $125 retail allowance

Up to $37 retail Up to $68 retail

Covered in full

Not Covered

$50 retail allowance

Not Covered

BCISD contributes $6.04 towards the premium EE Only $0 EE + Spouse $5.96 EE + Child(ren) $5.71 EE+ Family $11.84

$120 retail allowance Up to $100 retail

Co-Pays

Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive

Covered in full Covered in full Covered in full See description3

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

Exam

$10

Materials₁ Contact Lens Fitting (standard & specialty)

$25

Services/Frequency

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: 20% off amount over allowance Lens options: 20% off retail Progressives: 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.

$25

Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

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

$13 $15 $25 $50 $40 $55 $80

$13 $15 $25 $50 20% off retail 20% off retail 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 39 department if you have any questions.


ONEAMERICA YOUR BENEFITS PACKAGE

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 40 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


Disability Why Do I Need Disability?

Benefit Reductions

Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. Burnet CISD offers two Disability Plans: Short-Term and Long-Term. All new or increases in coverage are subject to pre-existing condition exclusions.

Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:  Social Security Disability Insurance (please see www.mybenefitshub.com/burnetcisd for exceptions)  Workers' Compensation  Other employer-based Insurance coverage you may have  Unemployment benefits  Settlements or judgments for income loss  Retirement benefits that your employer fully or partially pays for (such as a pension plan.)  Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  Retirement benefits that are funded by your aftertax contributions  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases  Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

Short-Term Disability For the Short-Term Disability Plan—designed to provide income to an individual that is disabled for a shorter period due to an accident or illness. There are 14 and 30 day elimination period options. Coverage is 60% of weekly earnings to a maximum of $1,385 per week. All new or increases in coverage are subject to pre-existing condition exclusions.

Long-Term Disability For the Long-Term Disability Plan – Designed to provide a monthly income to an individual that is disabled for a longer period due to an accident or illness. There are 90 and 180 day elimination periods available. Coverage is 60% of you monthly income up to $6,000 per month. All new or increases in coverage are subject to pre-existing condition exclusions.

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 pre-existing 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.

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

41


Short-Term Disability

Short-Term Disability Rates (Cost Per $100 of covered earnings)

42

Age

30 Day Elimination

14 Day Elimination

Under Age 30

$0.26

$0.34

30-34

$0.26

$0.34

35-39

$0.26

$0.34

40-44

$0.38

$0.51

45-49

$0.51

$0.69

50-54

$0.76

$0.76

55-59

$1.01

$1.01

60+

$1.17

$1.17


Long-Term Disability

Long-Term Disability Rates (Cost Per $100 of covered earnings) Age

90 Day Elimination

180 Day Elimination

Under Age 30

$0.126

$0.081

30-34

$0.180

$0.117

35-39

$0.270

$0.171

40-44

$0.432

$0.342

45-49

$0.612

$0.450

50-54

$0.900

$0.666

55-59

$1.206

$0.882

60+

$1.431

$1.035

Long-Term Disability Benefit Duration Age Prior to Age 62

Benefits Payable To Normal Retirement Age or 42 months if greater

Age 63

36 Months

Age 64

30 Months

Age 65

24 Months

Age 66

21 Months

Age 67

18 Months

Age 68

15 Months

Age 69 and older

12 Months

43


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 44 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

45

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. 46

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

47

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


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 48 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


Life and AD&D Benefit Reduction

Basic Term Life and AD&D Burnet CISD provides you with Basic Term Life & Accidental Death & Dismemberment (AD&D) insurance coverage in the amount of $30,000 at no cost to you.

Benefits reduce to 65% of face value at age 65, 50% at age 70, and 25% at age 75.

Voluntary AD&D Supplemental Term Life Employee Coverage $10,000 increments to a maximum of the lesser of 7 times your basic annual earnings or $500,000.

Accidental Death and Dismemberment (AD&D) insurance pays a benefit – in addition to your Basic/Optional Life benefit – in case you die in a covered accident or suffer loss of a limb or paralysis. Also, AD&D pays a benefit for covered accidents resulting in loss of sight, speech, hearing and thumb/index finger.

Guaranteed Issue coverage is available for new hires if:  Your enrollment takes place within 31 days from the date you become eligible for benefits, and  You are enrolling for coverage equal to/less than $200,000

Employee Coverage  Benefit Amount—Units of $10,000 The maximum amount of coverage you can receive is $500,000.

If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.

Dependent Coverage You can choose to cover your dependent spouse and child(ren) with AD&D coverage under the Family Plan. Your dependents will be eligible for the following coverage:

Dependent Coverage Spouse- $10,000 increments to a maximum of the lesser of 100% of Employee Life Benefits or $500,000. Guaranteed Issue coverage is available for new hires if:  The enrollment takes place within 31 days from the date you become eligible for benefits, and  You are enrolling your spouse for coverage equal to/less than $50,000. If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form. Dependent Children* $1,000 increments to a maximum of $10,000. *Child(ren)’s Eligibility: Unmarried Dependent children under the age of 26.

Age

EE Cost per $10,000

Spouse Cost per $10,000

<29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75 + Cost for your Child(ren)

$0.50 $0.70 $0.80 $1.00 $1.40 $2.40 $3.90 $5.90 $8.26 $10.30 $14.70 $1.80

$0.50 $0.70 $0.80 $1.00 $1.40 $2.40 $3.90 $5.90 $8.26

Dependent Spouse and Child(ren):  Spouse — 50% of your coverage amount Maximum—$250,000.  Child(ren) — 10% of your coverage amount Maximum—$50,000.00

What is not covered?       

Suicide while sane or insane, or intentionally self-inflicted injuries. Bodily or mental infirmity or disease of any kind, or infection unless due to an accidental cut or wound. Committing or attempting to commit an assault, felony or other illegal act. Active participation in a war (declared or undeclared) or active duty in any armed service during a time of war. Active participation in a riot, rebellion, or insurrection. Injury sustained from any aviation activities, other than riding as a fare-paying passenger, if the pilot exclusion applies to the plan. The Insured Person’s voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended, unless administered on the advice of a Physician. The Insured Person’s operation of any motorized vehicle while intoxicated. Intoxicated means the minimum blood level alcohol required to be considered operating an automobile under the influence of alcohol in the jurisdiction where the accident occurred. For the purpose of this Exclusion, "Motorized Vehicle" includes, but is not limited to, automobiles, motorcycles, boats and snowmobiles. AD&D Supplemental Coverage Employee Family

Monthly Cost per $10,000 $0.50 $0.80 49


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 50 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


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

51


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

52

$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.

53


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 54 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


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.

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

55


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 56 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


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

57


NBS

403(b) Plan

YOUR BENEFITS PACKAGE

About this Benefit A 403(b) plan is a U.S. tax-advantaged retirement savings plan available for public education organizations. Only 22% of workers are very confident they will have enough money in retirement.

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 58 Burnet CISD Benefits Website: www.mybenefitshub.com/burnetcisd


403(b) Plan To begin contributing to a 403(b) account, you would need to complete the following steps: 1. Determine which company you would like to invest your contributions with. A list of approved vendors can be found by accessing the NBS website at http://nbsbenefits.com/my account/national-benefit-services-403b-plan-information-portal/ 2. Contact the vendor of your choosing directly to obtain and submit all necessary paperwork to open the account. 3. Up to 2% match provided by BCISD for 403(b) contributions (50% match program through Fidelity). Employees are required to set up an account with Fidelity in order to receive the employer match. Employees may choose any investment provider from the approved vendor list for their employee contribution. 4. Complete a Salary Reduction Agreement and submit to National Benefit Services via mail or fax. 5. NBS will then approve the deductions and work with your district so deductions can begin flowing to your new account. NOTE: NBS is not licensed to offer investment advice, but if you need assistance, most companies have agents working in your area that can assist you. Please contact NBS if you have any further questions at 512-756-2124.

Universal Availability Notice You are eligible to participate in the 403(b) retirement plan sponsored by Burnet Consolidated Independent School District. Contributing to a 403(b) plan will help to give you peace of mind through financial security during your retirement. A 403(b) plan will allow you to contribute a portion of your compensation as a pre‐tax or after‐tax (Roth) contribution (if allowed by your Employer) in order to save toward your retirement. Participation in the 403(b) plan is completely voluntary. If you are already contributing to the 403(b) plan, now is a perfect time to increase your contributions.

What is a 403(b) Plan? A 403(b) plan, also known as a Tax‐Sheltered Annuity (TSA) plan, is a tax‐deferred retirement plan for employees of certain tax‐ exempt, governmental organizations or public education institutions. An employer may sponsor a 403(b) plan to provide a benefit to its employees to save for retirement on a tax‐deferred basis.

What are the benefits of contributing to a 403(b) Plan? LOWER TAXES TODAY The 403(b) contributions you make may be on a pretax basis. This means that you are taxed on a lower amount of income. For example, if your federal marginal income tax rate is 25%, and if you contribute $100 a month to a 403(b) plan, you have reduced your federal income taxes by nearly $25. In effect, your $100 contribution costs you only $75.The tax savings can grow with the size of your 403(b) contribution. TAX‐DEFERRED GROWTH In your 403(b) plan, interest and earnings accrue tax‐deferred. This means that your interest will grow tax‐free until the time of your withdrawal. The compounding interest on your 403(b) plan can allow your account to grow more quickly than saving money in a taxable account where interest and earnings are generally taxed each year. TAKING THE INITIATIVE Contributing to a 403(b) retirement plan can help you take control of your future retirement needs. Other sources of retirement income, including state pension plans and, if applicable, Social Security, often do not adequately replace a person’s salary upon retirement. A 403(b) plan can be a great way to provide you with additional income at retirement. POSSIBLE TAX CREDITS If you contribute to the plan, you may be able to receive a tax credit, which could reduce your overall federal income tax paid for the year. ROTH You may also choose to save part of your earnings on an AFTER -TAX (ROTH) basis. Qualified distributions will allow you to withdraw your money tax‐free.

How much can you contribute to a 403 (b) Plan? You may elect to save:  Up to 100% of your income  Up to $18,000 in 2015  Extra $5,500 if age 50+

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403(b) Plan Initial Eligibility

Contribution Changes

You must meet the following requirements to become eligible to contribute to the 403(b) Plan:

You may change the amount of your contribution during any pay period.

Employee Deferrals  Immediate Eligibility Employer Match  Employees Participating in the Teacher Retirement System

Investment Choices

After meeting the above requirements, newly eligible employees may enroll in the plan on the next entry date. Your plan provides for immediate entry dates.

Annuity contracts provided through an insurance company or custodial accounts provided through a retirement account custodian are allowed in 403(b) plans. For more information and a list of approved investment providers for your plan, visit http://www.nbsbenefits.com/403b. You will need to contact the investment providers for a comprehensive listing and for information regarding the available investment choices they provide.

The following types of Employees are excluded from the Plan:  Student Employees

Vesting

The following types of Employees are excluded from the Employer Match:  Employee not Participating in the Teacher Retirement System

You always own 100% of the contributions you make to the 403(b) and their earnings. Company contributions, if any, vest at the following rate, based upon your years of service with the company: Vesting Schedule—100% Immediate

How to Enroll in the Plan

Exchanges

You will need to make an election regarding how much of your compensation you wish to defer to the 403(b) plan. You will also need to determine which company you would like to invest your contributions with. A list of approved vendors and the Salary Reduction Agreement can be found by visiting the National Benefit Services website at www.nbsbenefits.com/403b or by contacting 512-756-2124. Once you have decided how much to contribute and which vendor to invest your funds, please contact the vendor directly to obtain and submit all necessary paperwork to open the account.

As a participant in the 403(b) Plan, you have the option to request a tax‐free contract exchange between different investment providers within the same plan. For a list of exchange eligible investment providers for your 403(b) Plan, please visit www.nbsbenefits.com/403b

Company Contributions The company may elect to match part of your contributions. Company contributions are discretionary and will be announced when made.

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Distributions from the Plan You or your beneficiary will be able to withdraw your vested balance when one of the following occurs: 1. Retirement 2. Total Disability 3. Death 4. Termination of Employment 5. Attainment of Age 59 ½ Please visit our website www.nbsbenefits.com. Note: The Vendors may require additional paperwork.


403(b) Plan Loans You may borrow up to ½ of your vested balance up to $50,000 (whichever is less). Contact your current Vendor about the Loan Policy for your Plan.

Hardship Distributions Your plan may allow for Hardship Distributions – contact your HR Department for more information about the requirements. NOTE: If you take a hardship distribution you are required to stop making contributions for 6 months.

General Plan Information To obtain additional information about participation, and about the savings products made available under the plan, please contact your human resources department. Plan Name: Burnet Consolidated Independent School District 403(b) Plan Plan Administrator: National Benefit Services Plan Contact Person: HR Department 208 East Brier Burnet, TX 78611 (512)715‐5103

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WWW.MYBENEFITSHUB.COM/BURNETCISD 64

2018 Benefit Guide ESC Region 20 Burnet ISD Version  
2018 Benefit Guide ESC Region 20 Burnet ISD Version