2018 Benefit Guide Southside ISD

SOUTHSIDE ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2018 - 08/31/2019 WWW.MYBENEFITSHUB.COM/ SOUTHSIDE

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions HSA Bank Health Savings Account Cigna Dental Avesis Vision The Hartford Disability Humana Cancer AUL a OneAmerica Company Life and AD&D Voya Accident Reliance Standard Critical Illness Texas Life Individual Life NBS Flexible Spending Accounts (FSAs) Dear Oaks Employee Assistance Program (EAP) Medical Gap Insurance MDLIVE Telehealth MASA Medical Transport

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PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information

Benefit Contact Information BENEFITS ADMINISTRATOR

CANCER

TELEHEALTH

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

Humana 800-448-6262 www.humana.com

MDLIVE (888) 365-1663 http://www.consultmdlive.com

MEDICAL

CRITICAL ILLNESS

INDIVIDUAL LIFE

TRS Active Care - Aetna (800) 222-9205 www.trsactivecareaetna.com

Reliance Standard 800-351-7500 www.reliancestandard.com

Texas Life (800) 283-9233 www.texaslife.com

MEDICAL SUPPLEMENT

ACCIDENT

HEALTH SAVINGS ACCOUNT (HSA)

Special Insurance Services, Inc. (800)767-6811

Voya (877) 236-7564 www.voya.com

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

DENTAL

BASIC AND VOLUNTARY LIFE

FLEXIBLE SPENDING ACCOUNTS (FSAs )

Cigna 800-244-6224 www.cigna.com

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

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

VISION

EMPLOYEE ASSISTANT PROGRAM

MEDICAL TRANSPORT

Avesis (800) 522-0258 www.avesis.com

Deer Oaks (866) 327-2400 www.deeroaks.com

MASA (800) 423-3226

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

www.masamts.com

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet.

Text “FBS SSISD” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information



Online Support



Interactive Tools



And more.

PLAY VIDEO

Text “FBS SSISD” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/southsideisd

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.

Annual Benefit Enrollment Benefit Updates - What’s New:  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 so you are covered anywhere nationwide. The Emergent plan covers your family for $9.00/month.  If you currently participate in a Healthcare or Dependent

Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app.  Humana Cancer plan. Cancer insurance offers you and

your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. Benefits are paid to you to help with medical and non-medical expenses associated with cancer treatment.

   

Login and complete your supplemental benefit enrollment from 05/01/2018 - 05/31/2018 Enrollment assistance is available by calling Financial Benefit Services at 866-583-6908 to speak to an enrollment representative Monday—Thursday, 8 AM—5:30 PM and Friday, 8 AM –3 PM from. Bilingual assistance is available.

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

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

SUMMARY PAGES

SUMMARY PAGES

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

Enrollment is automatic unless you decline this benefit.

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

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

Government Programs

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.

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



Changes, additions or drops may be made only during the

the Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

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

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

included in the dependent profile. Additionally, you must

Click on the benefit plan you need information on (i.e.,

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.

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 time frame 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 866-583-6908 for assistance.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within Southside ISD or as both

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

employees and dependents.

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

Medical

Aetna

To Age 26

Medical Supplement

Avesis

To Age 26

Accident

Voya

To Age 26

Cancer

Humana

To age 25 or to age 26 if full time student

Critical Illness

Reliance Standard

To Age 26

Dental

Cigna

To Age 26

Vision

Avesis

To Age 26

Voluntary Life and AD&D

AUL a OneAmerica Company

To Age 26

Individual Life

Texas Life

To Age 26

Medical Transport

MASA

To Age 26

If your dependent is disabled, coverage can 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.

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

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

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

(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 tax-free.

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

$1,300 single (2018) $2,600 family (2018) $3,450 single (2018) $6,900 family (2018)

N/A Varies per employer

Permissible Use Of Funds

If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

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. 12

FLIP TO FOR FSA INFORMATION

PG. 46

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

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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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan.

You may not enroll in the Medical Supplement plan if you participate in the HSA. You may not participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 

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

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

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

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

2018 Annual HSA Contribution Limits Individual: $3,450 Family: $6,900 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder  Age 55 or older (regardless of when in the year an accountholder turns 55)  Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated) Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the Southside ISD website at www.mybenefitshub.com/southsideisd

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

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

How an HSA works: 



 

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

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

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

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

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

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

What are the annual IRS contribution limits?

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

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

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

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

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

How can you benefit from tax savings?

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

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

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

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

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

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

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

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

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

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

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

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

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

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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

Dental PPO - High Plan Cigna Dental Choice Plan Network Options

In-Network: Total Cigna DPPO Network

Monthly PPO Premiums Out-of-Network: See Non-Network Reimbursement Maximum Reimbursable Charge

Reimbursement Levels Based on Contracted Fees Policy Year Benefits Maximum Applies to: Class I, II, & III expenses $1,200 $1,200 Policy Year Deductible Individual $50 $50 Family $150 $150 Benefit Highlights Plan Pays You Pay Plan Pays You Pay Class I: Diagnostic & Preventive 100% No Charge 100% No Charge Oral Evaluations No Deductible No Deductible Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Class II: Basic Restorative 80% 20% 80% 20% Emergency Care to Relieve Pain After Deductible After Deductible After Deductible After Deductible Restorative: fillings Oral Surgery: Simple Extractions Only Crowns: prefabricated stainless steel / resin Class III: Major Restorative 50% 50% 50% 50% Inlays and Onlays After Deductible After Deductible After Deductible After Deductible Prosthesis Over Implant Crowns: permanent cast and porcelain Bridges and Dentures Endodontics: minor and major Periodontics: minor and major Oral Surgery: All Except Simple Extractions Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments Class IV Benefit Waiting Period applies for 12 months. Applies to New Hires Only.

Class IV: Orthodontia Coverage for Employee and All Dependents Lifetime Benefits Maximum: $1,000

50% No Deductible

50% No Deductible

50% No Deductible

Tier

Rate

EE Only

$23.00

EE + Spouse

$42.69

EE + Children

$42.69

EE + Family

$67.60

Semi Monthly Premiums Tier

Rate

EE Only

$11.50

EE + Spouse

$21.35

EE + Children

$21.35

EE + Family

$33.80

50% No Deductible

This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

Dental PPO - High Plan Cigna Dental Choice Plan

Monthly PPO Premiums

Network Options

In-Network: Total Cigna DPPO Network

Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, & III expenses Policy Year Deductible Individual Family Benefit Highlights Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Class II: Basic Restorative Emergency Care to Relieve Pain Restorative: fillings Oral Surgery: Simple Extractions Only Crowns: prefabricated stainless steel / resin Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: permanent cast and porcelain Bridges and Dentures Endodontics: minor and major Periodontics: minor and major Oral Surgery: All Except Simple Extractions Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

Based on Contracted Fees

Out-of-Network: See Non-Network Reimbursement Maximum Allowable Charge

$1,000

$1,000

$50 $150

$50 $150

Plan Pays 100% No Deductible

You Pay No Charge

Plan Pays 100% No Deductible

You Pay No Charge

80% 20% 80% 20% After Deductible After Deductible After Deductible After Deductible

25% 75% 25% 75% After Deductible After Deductible After Deductible After Deductible

Tier

Rate

EE Only

$14.05

EE + Spouse

$32.40

EE + Children

$32.40

EE + Family

$53.41

Semi Monthly Premiums Tier

Rate

EE Only

$4.60

EE + Spouse

$16.20

EE + Children

$16.20

EE + Family

$26.71

Dental PPO - High and Low Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement Cross Accumulation Policy Year Benefits Maximum Policy Year Deductible Benefit Waiting Period Late Entrant Limitation Provision Pretreatment Review Alternate Benefit Provision Oral Health Integration Program (OHIP)

Timely Filing Benefit Limitations: Missing Tooth Limitation Oral Evaluations X-rays (routine) X-rays (non-routine) Diagnostic Casts Cleanings Fluoride Application Sealants (per tooth) Space Maintainers Inlays, Crowns, Bridges, Dentures and Partials Denture and Bridge Repairs Denture Adjustments, Rebases and Relines Prosthesis Over Implant

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.

For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area.

The dentist may balance bill up to their usual fees.

All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network.

The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply.

This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefitspecific deductibles may also apply.

No benefits will be paid for charges incurred during any applicable Benefit Waiting Period.

Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

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.

Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

Out of network claims submitted to Cigna after 365 days from date of service will be denied.

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense.

2 per policy year Bitewings: 2 per policy year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 3 policy years Payable only in conjunction with orthodontic workup 2 per policy year, including periodontal maintenance procedures following active therapy 1 per policy year for children under age 19 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Limited to non-orthodontic treatment for children under age 19 Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Reviewed if more than once Covered if more than 6 months after installation 1 every 60 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.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not listed under Benefit Highlights; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and/or third molars; Periodontic: bite registrations; splinting; Prosthodontic: precision or semi-precision attachments; Implants: implants or implant related services; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; Replacement of a lost or stolen appliance; Services performed primarily for cosmetic reasons; Personalization; Services that are deemed to be medical in nature; Services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge.

Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees.

AVESIS 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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

Vision Vision Care Services

In-Network Member Benefits

Out-of-Network Reimbursement

Eye Examination Materials: $10 copayment

Covered in full after $0 (Materials copay applies to frame or spectacle lenses, if applicable.)

Members receive a $50wholesale allowance Up to $150retail value†

Up to $40.00

Covered in full after materials copay Covered in full after materials copay Covered in full after materials copay Covered in full after materials copay Covered up to $50, plus 20% off retail

Up to $40.00 Up to $60.00 Up to $80.00 Up to $80.00 up to $60.00

Frame Allowance* Standard Spectacle Lenses Single Vision Bifocal Trifocal Lenticular Standard Progressives Other Lens Options‡ Level 1 Lens Option Package Youth Polycarbonate (Up to Age 19)

Up to $45.00

Lens Options are discounted up to 20% off retail

Contact Lenses§ (in lieu of frame and spectacle lenses) Elective Medically Necessary Refractive Laser Surgery

Employee Paid Rates Per Month Employee

$9.19

Employee + Spouse

$16.26

Employee + Child(ren)

$19.23

Employee + Family

$23.96

Semi-Monthly Employee Paid Rates Employee

$4.60

Employee + Spouse

$8.13

Employee + Child(ren)

$9.62

Employee + Family

$11.98

‡ Discounts

are not insured benefits authorization is required for medically necessary contacts. § Prior

$130 allowance Covered in full Provider discount up to 25% One-time/lifetime allowance of $150

$130.00 $250.00 $150.00

Once every 12 Months Once every 12 Months Once every 12 Months

Once every 12 Months Once every 12 Months Once every 12 Months

Frequency Eye Examination Lenses or contact lenses Frame

3.

Members who elect to use an out-of-network provider must pay 4.

5. the provider in full at the time of service and submit a claim to Avēsis for reimbursement. Reimbursement levels are in 6. accordance with the out-of-network reimbursement schedule previously listed. Out-of-network benefits are subject to the same eligibility, availability, frequency of benefits, and limitation 7. and exclusion provisions of the plan, and are in lieu of services provided by a participating Avēsis provider. Out-of-network claim forms can be obtained by contacting Avēsis’ Customer 8.

Service Center or your group administrator, or by visiting www.avesis.com.

Using Out-of-Network Providers

Limitations and Exclusions

Plano (non-prescription) lenses, sunglasses; Two pair of glasses in lieu of bifocal lenses; Any medical or surgical treatment of eye or supporting structures; Replacement of lost or broken lenses, contact lenses or frames, except when the member is normally eligible for services; Any eye examination or corrective eyewear required by an employer as a condition of employment and safety eyewear; Services or materials provided as a result of Workers’ Compensation Law, or similar legislation, required by any governmental agency whether Federal, State, or subdivision thereof.

Services or materials provided by any other group benefit plan providing vision care.

Some provisions, benefits, exclusions or limitations listed herein may vary depending on your state of residence.

9.

Limitations: This plan is designed to cover eye examinations and corrective eyewear. It is also designed to cover visual needs rather than cosmetic options. Should the member select options that are not covered under the plan, as shown in the schedule of benefits, the member will pay a discounted fee to the participating Avesis provider. Benefits are payable only for services received while the group and individual member’s coverage is in force.

Refractive Surgery Vision Benefit Exclusions: Benefits are not payable for any of the following: 1. Routine vision examinations or corrective vision materials, including corrective eyeglasses, fittings, lenses, frames, or contact lenses; or 2. Medical or surgical procedures, services, or treatments: a. not specifically covered under this Rider; b. provided free of charge in the absence of insurance c. payable under any Workers’ Compensation law or similar statutory authority d. payable under governmental plan or program, whether Federal, state, or subdivisions thereof.

Exclusions: There are no benefits under the plan for professional services or materials connected with and arising from: 1. Orthoptics or vision training; 2. Subnormal vision aids and any supplemental testing, aniseikonic lenses;

THE HARTFORD 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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

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



Pre-existing Conditions



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

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



Mental Illness, Alcoholism and Substance Abuse



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

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

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

What other benefits are included in my disability coverage? 







Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  Retirement benefits that are funded by your after-tax contributions  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

Any case where your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits



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

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

Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less.

Services include pre-trip information, emergency medical assistance and emergency personal services.

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

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

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

Long Term Disability Option 1: Premium Option For the Premium benefit option – Benefits are payable for disabilities resulting from Sickness or Injury to normal retirement age if you are disabled prior to age 63. The table below details the applicable benefit duration based on the age you are disabled.

Age Disabled

Benefits Payable

Prior to Age 63

To Normal Retirement Age or 48 months if greater

Age 63

To Normal Retirement Age or 42 months if greater

Age 64

36 months

Age 65

30 months

Age 66

27 months

Age 67

24 months

Age 68

21 months

Age 69 and older

18 months

Option 2: Select Option For the Select benefit option – Benefits are payable for disabilities resulting from Sickness for 5 years & Injury to normal retirement age if you are disabled prior to age 63. The table below details the applicable benefit duration based on the age you are disabled.

Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older Age Disabled Prior to Age 65 Age 65 to 69 Age 69 and older

Benefits Payable for a Disability Caused by Injury To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months Benefits Payable for a Disability Caused by Sickness 3 Years To Age 70, but not less than one year 1 Year

Long Term Disability Premium Option – Monthly Premium Cost (based on 12 payments per year) Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 /180

$3,600

$300

$200

$6.82

$5.82

$4.82

$3.40

$2.90

$2.12

$5,400

$450

$300

$10.23

$8.73

$7.23

$5.10

$4.35

$3.18

$7,200

$600

$400

$13.64

$11.64

$9.64

$6.80

$5.80

$4.24

$9,000

$750

$500

$17.05

$14.55

$12.05

$8.50

$7.25

$5.30

$10,800

$900

$600

$20.46

$17.46

$14.46

$10.20

$8.70

$6.36

$12,600

$1,050

$700

$23.87

$20.37

$16.87

$11.90

$10.15

$7.42

$14,400

$1,200

$800

$27.28

$23.28

$19.28

$13.60

$11.60

$8.48

$16,200

$1,350

$900

$30.69

$26.19

$21.69

$15.30

$13.05

$9.54

$18,000

$1,500

$1,000

$34.10

$29.10

$24.10

$17.00

$14.50

$10.60

$19,800

$1,650

$1,100

$37.51

$32.01

$26.51

$18.70

$15.95

$11.66

$21,600

$1,800

$1,200

$40.92

$34.92

$28.92

$20.40

$17.40

$12.72

$23,400

$1,950

$1,300

$44.33

$37.83

$31.33

$22.10

$18.85

$13.78

$25,200

$2,100

$1,400

$47.74

$40.74

$33.74

$23.80

$20.30

$14.84

$27,000

$2,250

$1,500

$51.15

$43.65

$36.15

$25.50

$21.75

$15.90

$28,800

$2,400

$1,600

$54.56

$46.56

$38.56

$27.20

$23.20

$16.96

$30,600

$2,550

$1,700

$57.97

$49.47

$40.97

$28.90

$24.65

$18.02

$32,400

$2,700

$1,800

$61.38

$52.38

$43.38

$30.60

$26.10

$19.08

$34,200

$2,850

$1,900

$64.79

$55.29

$45.79

$32.30

$27.55

$20.14

$36,000

$3,000

$2,000

$68.20

$58.20

$48.20

$34.00

$29.00

$21.20

$37,800

$3,150

$2,100

$71.61

$61.11

$50.61

$35.70

$30.45

$22.26

$39,600

$3,300

$2,200

$75.02

$64.02

$53.02

$37.40

$31.90

$23.32

$41,400

$3,450

$2,300

$78.43

$66.93

$55.43

$39.10

$33.35

$24.38

$43,200

$3,600

$2,400

$81.84

$69.84

$57.84

$40.80

$34.80

$25.44

$45,000

$3,750

$2,500

$85.25

$72.75

$60.25

$42.50

$36.25

$26.50

$46,800

$3,900

$2,600

$88.66

$75.66

$62.66

$44.20

$37.70

$27.56

$48,600

$4,050

$2,700

$92.07

$78.57

$65.07

$45.90

$39.15

$28.62

$50,400

$4,200

$2,800

$95.48

$81.48

$67.48

$47.60

$40.60

$29.68

$52,200

$4,350

$2,900

$98.89

$84.39

$69.89

$49.30

$42.05

$30.74

$54,000

$4,500

$3,000

$102.30

$87.30

$72.30

$51.00

$43.50

$31.80

$55,800

$4,650

$3,100

$105.71

$90.21

$74.71

$52.70

$44.95

$32.86

$57,600

$4,800

$3,200

$109.12

$93.12

$77.12

$54.40

$46.40

$33.92

$59,400

$4,950

$3,300

$112.53

$96.03

$79.53

$56.10

$47.85

$34.98

$61,200

$5,100

$3,400

$115.94

$98.94

$81.94

$57.80

$49.30

$36.04

$63,000

$5,250

$3,500

$119.35

$101.85

$84.35

$59.50

$50.75

$37.10

$64,800

$5,400

$3,600

$122.76

$104.76

$86.76

$61.20

$52.20

$38.16

$66,600

$5,550

$3,700

$126.17

$107.67

$89.17

$62.90

$53.65

$39.22

$68,400

$5,700

$3,800

$129.58

$110.58

$91.58

$64.60

$55.10

$40.28

$70,200

$5,850

$3,900

$132.99

$113.49

$93.99

$66.30

$56.55

$41.34

$72,000

$6,000

$4,000

$136.40

$116.40

$96.40

$68.00

$58.00

$42.40

$73,800

$6,150

$4,100

$139.81

$119.31

$98.81

$69.70

$59.45

$43.46

$75,600

$6,300

$4,200

$143.22

$122.22

$101.22

$71.40

$60.90

$44.52

$77,400

$6,450

$4,300

$146.63

$125.13

$103.63

$73.10

$62.35

$45.58

$79,200

$6,600

$4,400

$150.04

$128.04

$106.04

$74.80

$63.80

$46.64

Disability Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

$81,000

$6,750

$4,500

$153.45

$82,800

$6,900

$4,600

$84,600

$7,050

$86,400

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$130.95

$108.45

$76.50

$65.25

$47.70

$156.86

$133.86

$110.86

$78.20

$66.70

$48.76

$4,700

$160.27

$136.77

$113.27

$79.90

$68.15

$49.82

$7,200

$4,800

$163.68

$139.68

$115.68

$81.60

$69.60

$50.88

$88,200

$7,350

$4,900

$167.09

$142.59

$118.09

$83.30

$71.05

$51.94

$90,000

$7,500

$5,000

$170.50

$145.50

$120.50

$85.00

$72.50

$53.00

$91,800

$7,650

$5,100

$173.91

$148.41

$122.91

$86.70

$73.95

$54.06

$93,600

$7,800

$5,200

$177.32

$151.32

$125.32

$88.40

$75.40

$55.12

$95,400

$7,950

$5,300

$180.73

$154.23

$127.73

$90.10

$76.85

$56.18

$97,200

$8,100

$5,400

$184.14

$157.14

$130.14

$91.80

$78.30

$57.24

$99,000

$8,250

$5,500

$187.55

$160.05

$132.55

$93.50

$79.75

$58.30

$100,800

$8,400

$5,600

$190.96

$162.96

$134.96

$95.20

$81.20

$59.36

$102,600

$8,550

$5,700

$194.37

$165.87

$137.37

$96.90

$82.65

$60.42

$104,400

$8,700

$5,800

$197.78

$168.78

$139.78

$98.60

$84.10

$61.48

$106,200

$8,850

$5,900

$201.19

$171.69

$142.19

$100.30

$85.55

$62.54

$108,000

$9,000

$6,000

$204.60

$174.60

$144.60

$102.00

$87.00

$63.60

$109,800

$9,150

$6,100

$208.01

$177.51

$147.01

$103.70

$88.45

$64.66

$111,600

$9,300

$6,200

$211.42

$180.42

$149.42

$105.40

$89.90

$65.72

$113,400

$9,450

$6,300

$214.83

$183.33

$151.83

$107.10

$91.35

$66.78

$115,200

$9,600

$6,400

$218.24

$186.24

$154.24

$108.80

$92.80

$67.84

$117,000

$9,750

$6,500

$221.65

$189.15

$156.65

$110.50

$94.25

$68.90

$118,800

$9,900

$6,600

$225.06

$192.06

$159.06

$112.20

$95.70

$69.96

$120,600

$10,050

$6,700

$228.47

$194.97

$161.47

$113.90

$97.15

$71.02

$122,400

$10,200

$6,800

$231.88

$197.88

$163.88

$115.60

$98.60

$72.08

$124,200

$10,350

$6,900

$235.29

$200.79

$166.29

$117.30

$100.05

$73.14

$126,000

$10,500

$7,000

$238.70

$203.70

$168.70

$119.00

$101.50

$74.20

$127,800

$10,650

$7,100

$242.11

$206.61

$171.11

$120.70

$102.95

$75.26

$129,600

$10,800

$7,200

$245.52

$209.52

$173.52

$122.40

$104.40

$76.32

$131,400

$10,950

$7,300

$248.93

$212.43

$175.93

$124.10

$105.85

$77.38

$133,200

$11,100

$7,400

$252.34

$215.34

$178.34

$125.80

$107.30

$78.44

$135,000

$11,250

$7,500

$255.75

$218.25

$180.75

$127.50

$108.75

$79.50

$136,800

$11,400

$7,600

$259.16

$221.16

$183.16

$129.20

$110.20

$80.56

$138,600

$11,550

$7,700

$262.57

$224.07

$185.57

$130.90

$111.65

$81.62

$140,400

$11,700

$7,800

$265.98

$226.98

$187.98

$132.60

$113.10

$82.68

$142,200

$11,850

$7,900

$269.39

$229.89

$190.39

$134.30

$114.55

$83.74

$144,000

$12,000

$8,000

$272.80

$232.80

$192.80

$136.00

$116.00

$84.80

Disability Select Option – Monthly Premium Cost (based on 12 payments per year) Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

30 / 30

60 / 60

90 / 90

180 /180

$5.14

14 / 14 $4.06

$3.26

$2.92

$2.44

$1.82

$3,600

$300

$200

$5,400

$450

$300

$7.71

$6.09

$4.89

$4.38

$3.66

$2.73

$8.12

$6.52

$5.84

$4.88

$3.64

$7,200

$600

$400

$10.28

$9,000

$750

$500

$12.85

$10.15

$8.15

$7.30

$6.10

$4.55

$10,800

$900

$600

$15.42

$12.18

$9.78

$8.76

$7.32

$5.46

$12,600

$1,050

$700

$17.99

$14.21

$11.41

$10.22

$8.54

$6.37

$16.24

$13.04

$11.68

$9.76

$7.28

$14,400

$1,200

$800

$20.56

$16,200

$1,350

$900

$23.13

$18.27

$14.67

$13.14

$10.98

$8.19

$20.30

$16.30

$14.60

$12.20

$9.10

$18,000

$1,500

$1,000

$25.70

$19,800

$1,650

$1,100

$28.27

$22.33

$17.93

$16.06

$13.42

$10.01

$21,600

$1,800

$1,200

$30.84

$24.36

$19.56

$17.52

$14.64

$10.92

$26.39

$21.19

$18.98

$15.86

$11.83

$23,400

$1,950

$1,300

$33.41

$25,200

$2,100

$1,400

$35.98

$28.42

$22.82

$20.44

$17.08

$12.74

$27,000

$2,250

$1,500

$38.55

$30.45

$24.45

$21.90

$18.30

$13.65

$32.48

$26.08

$23.36

$19.52

$14.56

$28,800

$2,400

$1,600

$41.12

$30,600

$2,550

$1,700

$43.69

$34.51

$27.71

$24.82

$20.74

$15.47

$36.54

$29.34

$26.28

$21.96

$16.38

$32,400

$2,700

$1,800

$46.26

$34,200

$2,850

$1,900

$48.83

$38.57

$30.97

$27.74

$23.18

$17.29

$36,000

$3,000

$2,000

$51.40

$40.60

$32.60

$29.20

$24.40

$18.20

$42.63

$34.23

$30.66

$25.62

$19.11

$37,800

$3,150

$2,100

$53.97

$39,600

$3,300

$2,200

$56.54

$44.66

$35.86

$32.12

$26.84

$20.02

$41,400

$3,450

$2,300

$59.11

$46.69

$37.49

$33.58

$28.06

$20.93

$2,400

$61.68

$48.72

$39.12

$35.04

$29.28

$21.84

$50.75

$40.75

$36.50

$30.50

$22.75

$43,200

$3,600

$45,000

$3,750

$2,500

$64.25

$46,800

$3,900

$2,600

$66.82

$52.78

$42.38

$37.96

$31.72

$23.66

$2,700

$69.39

$54.81

$44.01

$39.42

$32.94

$24.57

$56.84

$45.64

$40.88

$34.16

$25.48

$48,600

$4,050

$50,400

$4,200

$2,800

$71.96

$52,200

$4,350

$2,900

$74.53

$58.87

$47.27

$42.34

$35.38

$26.39

$54,000

$4,500

$3,000

$77.10

$60.90

$48.90

$43.80

$36.60

$27.30

$55,800

$4,650

$3,100

$79.67

$62.93

$50.53

$45.26

$37.82

$28.21

$64.96

$52.16

$46.72

$39.04

$29.12

$57,600

$4,800

$3,200

$82.24

$59,400

$4,950

$3,300

$84.81

$66.99

$53.79

$48.18

$40.26

$30.03

$61,200

$5,100

$3,400

$87.38

$69.02

$55.42

$49.64

$41.48

$30.94

$71.05

$57.05

$51.10

$42.70

$31.85

$63,000

$5,250

$3,500

$89.95

$64,800

$5,400

$3,600

$92.52

$73.08

$58.68

$52.56

$43.92

$32.76

$75.11

$60.31

$54.02

$45.14

$33.67

$66,600

$5,550

$3,700

$95.09

$68,400

$5,700

$3,800

$97.66

$77.14

$61.94

$55.48

$46.36

$34.58

$70,200

$5,850

$3,900

$100.23

$79.17

$63.57

$56.94

$47.58

$35.49

$81.20

$65.20

$58.40

$48.80

$36.40

$72,000

$6,000

$4,000

$102.80

$73,800

$6,150

$4,100

$105.37

$83.23

$66.83

$59.86

$50.02

$37.31

$75,600

$6,300

$4,200

$107.94

$85.26

$68.46

$61.32

$51.24

$38.22

$87.29

$70.09

$62.78

$52.46

$39.13

$89.32

$71.72

$64.24

$53.68

$40.04

$77,400

$6,450

$4,300

$110.51

$79,200

$6,600

$4,400

$113.08

Disability Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$81,000

$6,750

$4,500

$115.65

$91.35

$73.35

$65.70

$54.90

$40.95

$82,800

$6,900

$4,600

$118.22

$93.38

$74.98

$67.16

$56.12

$41.86

$84,600

$7,050

$4,700

$120.79

$95.41

$76.61

$68.62

$57.34

$42.77

$86,400

$7,200

$4,800

$123.36

$97.44

$78.24

$70.08

$58.56

$43.68

$88,200

$7,350

$4,900

$125.93

$99.47

$79.87

$71.54

$59.78

$44.59

$90,000

$7,500

$5,000

$128.50

$101.50

$81.50

$73.00

$61.00

$45.50

$91,800

$7,650

$5,100

$131.07

$103.53

$83.13

$74.46

$62.22

$46.41

$93,600

$7,800

$5,200

$133.64

$105.56

$84.76

$75.92

$63.44

$47.32

$95,400

$7,950

$5,300

$136.21

$107.59

$86.39

$77.38

$64.66

$48.23

$97,200

$8,100

$5,400

$138.78

$109.62

$88.02

$78.84

$65.88

$49.14

$99,000

$8,250

$5,500

$141.35

$111.65

$89.65

$80.30

$67.10

$50.05

$100,800

$8,400

$5,600

$143.92

$113.68

$91.28

$81.76

$68.32

$50.96

$102,600

$8,550

$5,700

$146.49

$115.71

$92.91

$83.22

$69.54

$51.87

$104,400

$8,700

$5,800

$149.06

$117.74

$94.54

$84.68

$70.76

$52.78

$106,200

$8,850

$5,900

$151.63

$119.77

$96.17

$86.14

$71.98

$53.69

$108,000

$9,000

$6,000

$154.20

$121.80

$97.80

$87.60

$73.20

$54.60

$109,800

$9,150

$6,100

$156.77

$123.83

$99.43

$89.06

$74.42

$55.51

$111,600

$9,300

$6,200

$159.34

$125.86

$101.06

$90.52

$75.64

$56.42

$113,400

$9,450

$6,300

$161.91

$127.89

$102.69

$91.98

$76.86

$57.33

$115,200

$9,600

$6,400

$164.48

$129.92

$104.32

$93.44

$78.08

$58.24

$117,000

$9,750

$6,500

$167.05

$131.95

$105.95

$94.90

$79.30

$59.15

$118,800

$9,900

$6,600

$169.62

$133.98

$107.58

$96.36

$80.52

$60.06

$120,600

$10,050

$6,700

$172.19

$136.01

$109.21

$97.82

$81.74

$60.97

$122,400

$10,200

$6,800

$174.76

$138.04

$110.84

$99.28

$82.96

$61.88

$124,200

$10,350

$6,900

$177.33

$140.07

$112.47

$100.74

$84.18

$62.79

$126,000

$10,500

$7,000

$179.90

$142.10

$114.10

$102.20

$85.40

$63.70

$127,800

$10,650

$7,100

$182.47

$144.13

$115.73

$103.66

$86.62

$64.61

$129,600

$10,800

$7,200

$185.04

$146.16

$117.36

$105.12

$87.84

$65.52

$131,400

$10,950

$7,300

$187.61

$148.19

$118.99

$106.58

$89.06

$66.43

$133,200

$11,100

$7,400

$190.18

$150.22

$120.62

$108.04

$90.28

$67.34

$135,000

$11,250

$7,500

$192.75

$152.25

$122.25

$109.50

$91.50

$68.25

$136,800

$11,400

$7,600

$195.32

$154.28

$123.88

$110.96

$92.72

$69.16

$138,600

$11,550

$7,700

$197.89

$156.31

$125.51

$112.42

$93.94

$70.07

$140,400

$11,700

$7,800

$200.46

$158.34

$127.14

$113.88

$95.16

$70.98

$142,200

$11,850

$7,900

$203.03

$160.37

$128.77

$115.34

$96.38

$71.89

$144,000

$12,000

$8,000

$205.60

$162.40

$130.40

$116.80

$97.60

$72.80

Disability

HUMANA

Cancer

YOUR BENEFITS PACKAGE

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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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

Cancer Base Policy

Base Policy Semi-Monthly Rates

Coverage Tier

Low

High

Coverage Tier

Low

High

Individual Individual + Spouse Individual + Child(ren) Family

$9.76 $19.63 $13.57 $23.44

$19.79 $39.67 $27.57 $47.45

Individual Individual + Spouse Individual + Child(ren) Family

$4.88 $9.82 $6.79 $11.72

$9.90 $19.84 $13.79 $23.73

Variable Benefit Elections Benefit

Low

High

Hospital Confinement Surgical Radiation/Chemotherapy First Diagnosis Colony Stimulating Factors Wellness

$100 per day up to $1,500 $200 per day $2,500 $500 per month $50 per year

$200 per day up to $3,000 $500 per day $5,000 $500 per month $100 per year

Optional Intensive Care Rider

Optional Intensive Care Rider Semi-Monthly Rates

Coverage Tier

$325 per day

$625 per day

Coverage Tier

Low

High

Individual Individual + Spouse Individual + Child(ren) Family

$1.94 $4.05 $3.16 $5.27

$3.98 $8.31 $6.48 $10.82

Individual Individual + Spouse Individual + Child(ren) Family

$0.97 $2.03 $1.58 $2.64

$1.99 $4.16 $3.24 $5.41

Benefit

Low

High

Wellness Benefit. For Cancer screening tests such as mammogram, flexible sigmoidoscopy, pap smear, chest X-ray, hemocult stool specimen, or prostate screen. No Lifetime Maximum Positive Diagnosis Test. Payable for a test that leads to positive diagnosis of Cancer or Specified Disease within 90 days. This benefit is not payable if the same Cancer or Specified Disease recurs.

First Diagnosis Benefit. One-time benefit payable when a Covered Person is first diagnosed with Cancer (other than Skin Cancer) or a Specified Disease. Must occur after the Certificate Effective Date.

Second and Third Surgical Opinions. Covers written opinions received after a Positive Diagnosis and before surgery. No Lifetime Maximum

Up to $50 per calendar year

Up to $100 per calendar year

Up to $300 per calendar year

Up to $300 per calendar year

$2,500

$5,000

Actual Charges

Actual Charges

Actual charges by a common Non-Local Transportation. Payable for transportation to a Hospital, clinic or treatment center which carrier or 50 cents per mile if a is more than 60 miles and less than 700 miles from a Covered Person’s home. No Lifetime Maximum personal vehicle is used.

Adult Companion Lodging and Transportation. Payable for one adult companion to stay with a Covered Person who is confined in a Hospital that is more than 60 miles and less than 700 miles from Up to $75 per day for lodging. his or her home. Covered expenses include a single room in a motel or hotel up to 60 days per 50 cents per mile if a personal confinement; and the actual charge of round trip coach fare by a common carrier or a mileage vehicle is used. allowance for the use of a personal vehicle. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. No Lifetime Maximum Ambulance. For ambulance service if the Covered Person is taken to a Hospital and admitted as an Actual Charges inpatient. No Lifetime Maximum Surgery. Covers actual surgeon’s fee for an operation up to the amount listed on the schedule.

Benefits for surgery performed on an outpatient basis will be 150% of the schedule benefit amount, Up to $1,500 not to exceed the actual surgeon’s fees. No Lifetime Maximum Donor Benefit Bone Marrow and Stem Cell Transplant. a) $200 per day We will pay the following expenses incurred by the Covered Person and his or her live donor: b) Actual charges for round (a) Medical expense allowance of two times the selected Hospital Confinement benefit. (b) Actual trip coach fare; or charges for round trip coach fare on a Common Carrier to the city where the transplant is performed; personal automobile or personal automobile expense allowance of 50 cents per mile. Mileage is measured from the home expense of 50 cents per of the Donor or Covered Person to the Hospital in which the Covered Person is staying. We will pay for mile. up to 700 miles per Hospital stay. (c) Actual Charges up to $50 per day for lodging and meals expense c) Actual charges up to $50 for donor to remain near Hospital. per day Actual charges to a combined Bone Marrow and Stem Cell Transplant. We will pay Actual Charges per Covered Person for surgical lifetime maximum of $15,000 and anesthetic charges associated with bone marrow transplant and/or peripheral stem cell transplant Up to 25% of surgical benefit Anesthesia. paid.

For services of an anesthesiologist during a Covered Person’s surgery. No Lifetime Maximum $100 maximum per Covered For anesthesia in connection with the treatment of skin Cancer. No Lifetime Maximum Person Ambulatory Surgical Center. We will pay the expense incurred at an Ambulatory Surgical Center. No $250 Per Day Lifetime Maximum Drugs and Medicines. Payable for drugs and medicine received while the Covered Person is Hospital Up to $25 per day, confined. No Lifetime Maximum $600 per calendar year

Actual charges by a common carrier or 50 cents per mile if a personal vehicle is used.

Up to $75 per day for lodging.

50 cents per mile if a personal vehicle is used.

Actual Charges

Up to $3,000 d) e)

$400 per day Actual charges for round trip coach fare;or personal automobile expense of 50 cents per mile. f) Actual charges up to $50 per day Actual charges to a combined lifetime maximum of $15,000 Up to 25% of surgical benefit paid. $100 maximum per Covered Person $250 Per Day Up to $25 per day, $600 per calendar year

Cancer Benefit

Low

High

Outpatient Anti-Nausea Drugs. Payable for drugs prescribed by a Physician to suppress nausea due to Cancer or Specified Disease. No Lifetime Maximum

Up to $250 per calendar year

Up to $250 per calendar year

Radiation, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy. Covers treatment administered by Actual charges up to $200 Actual charges up to $500 a Radiologist, Chemotherapist or Oncologist on an inpatient or outpatient basis. No Lifetime Maximum per day per day Miscellaneous Therapy Charges. Covers charges for lab work or x-rays in connection with radiation and chemotherapy treatment. Service must be performed while receiving treatment(s) in Radiation, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy, or within 30 days following a covered treatment.

Self-Administered Drugs. We will pay the actual expenses incurred for self-administered chemotherapy, including hormone therapy, or immunotherapy agents. This benefit is not payable for planning, monitoring, or other agents used to treat or prevent side effects, or other procedures related to this therapy treatment. No Lifetime Maximum Colony Stimulating Factors. We will pay expenses incurred for: [a] cost of the chemical substances and [b] their administration to stimulate the production of blood cells. Treatment must be administered by an Oncologist or Chemotherapist. No Lifetime Maximum Blood, Plasma and Platelets. For blood, plasma and platelets, and transfusions: including administration. No Lifetime Maximum

Actual charges up to a lifetime maximum of $5,000 Actual charges up to $2,000 per month

Actual charges up to a lifetime maximum of $5,000 Actual charges up to $2,000 per month

Actual charges up to $500 per month

Actual charges up to $500 per month

Actual charges up to $200 per day

Actual charges up to $200 per day

Physician's Attendance. For one visit per day while Hospital confined. No Lifetime Maximum

Up to $35 per day

Up to $35 per day

Private Duty Nursing Service. For private nursing services ordered by the Physician while Hospital confined. No Lifetime Maximum

Up to $100 per day

Up to $100 per day

National Cancer Institute Designated Comprehensive Cancer Treatment Center Evaluation/Consultation Benefit. We will pay the expense incurred if an Covered Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Covered Person’s place of residence, We will also pay the transportation and lodging expenses incurred. This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation Benefits of the policy.

Breast Prosthesis. Covers the prosthesis and its implantation if it is required due to breast cancer. No Lifetime Maximum

Expenses incurred limited to a lifetime maximum up to $750 for evaluation.

Expenses incurred limited to a lifetime maximum up to $350 for transportation and lodging.

Actual Charges

Expenses incurred limited to a lifetime maximum up to $750 for evaluation.

Expenses incurred limited to a lifetime maximum up to $350 for transportation and lodging.

Actual Charges

Artificial Limb or Prosthesis. Covers implantation of an artificial limb or prosthesis when an amputation is performed.

$1,500 lifetime maximum $1,500 lifetime maximum per amputation. per amputation.

Physical or Speech Therapy. Payable when therapy is needed to restore normal bodily function. No Lifetime Maximum

Up to $35 per session

Extended Benefits. If a Covered Person is confined in a Hospital for 60 continuous days We will pay three times $300 per day the selected Hospital Confinement Benefit beginning on the 61st day for Hospital Confinement. This benefit is payable in place of the Hospital Confinement Benefit. No Lifetime Maximum Extended Care Facility. Limited to number of days of prior Hospital confinement. Must begin within 14 days after Up to $50 per day Hospital confinement, and be at the direction of the attending Physician.

No Lifetime Maximum At Home Nursing. Limited to number of days of prior Hospital confinement. Must begin immediately following a Up to $100 per day Hospital confinement, and be authorized by the attending Physician. No Lifetime Maximum New or Experimental Treatment. We will pay the expenses incurred by a Covered Person for New or Experimental Treatment judged necessary by the attending Physician and received in the United States or in its territories. No Lifetime Maximum Hospice Care. If a Covered Person elects to receive hospice care, We will pay the expenses incurred for care received in a Free Standing Hospice Care Center. No Lifetime Maximum Government or Charity Hospital. Payable if the Covered Person is confined in a U. S. Government Hospital or a Hospital that does not charge for its services. Paid in place of all other benefits under the Policy. No Lifetime Maximum

Up to $35 per session $600 per day

Up to $50 per day

Up to $100 per day

Up to $7,500 per calendar year

Up to $7,500 per calendar year

Up to $50 per day

Up to $50 per day

$200 per day

$200 per day

Hairpiece. We will pay the actual expense incurred per Covered Person for a hairpiece when hair loss is a result of Actual charge up to a Cancer Treatment. lifetime maximum of $150 Rental or Purchase of Durable Goods. We will pay the actual expenses incurred for the rental or purchase of the Actual charges up to following pieces of durable medical equipment: a respirator or similar mechanical device, brace, crutches, Hospital $1,500 per calendar year bed, or wheelchair. No Lifetime Maximum

Actual charge up to a lifetime maximum of $150

Waiver of Premium. After 60 continuous days of disability due to Cancer or Specified Disease, We will waive premiums starting on the first day of policy renewal.

After 60 days

After 60 days

Hospital Confinement. Payable for each day a Covered Person is charged the daily room rate by a Hospital, for up to 60 days of continuous stay. The benefit for covered children under age 21 is two times the Covered Person’s daily $100 per day benefit. No Lifetime Maximum

$200 per day

Actual charges up to $1,500 per calendar year

Cancer           

Addison’s Disease Amyotrophic Lateral Sclerosis Cystic Fibrosis Diphtheria Encephalitis Epilepsy Hansen’s Disease Legionnaire’s Disease Lupus Erythematosus Lyme Disease Malaria

          

Other Specified Diseases Covered: Meningitis (epidemic cerebrospinal) Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Niemann-Pick Disease Osteomyelitis Poliomyelitis Rabies Reye’s Syndrome Rheumatic Fever

         

Scarlet Fever Sickle Cell Anemia Tay-Sachs Disease Tetanus Toxic Epidermal Necrolysis Tuberculosis Tularemia Typhoid Fever Undulant Fever Whipple’s Disease

Rocky Mountain Spotted Fever

Payment Of Benefits Benefits are payable for a Covered Person’s Positive Diagnosis of a Cancer or Specified Disease that begins after the Certificate Effective Date and while this Certificate has remained in force.

Termination of Coverage

A Covered Person’s insurance under the Policy will automatically terminate on the earliest of the following dates: 1. the date that the Policy terminates.

2. the date of termination of any section or part of the Policy with respect to insurance under such section or part.

Pre-Existing Condition Limitation 3. the date the Policy is amended to terminate the eligibility During the first 12 months of a Covered Person’s insurance, of the Employee class. losses incurred for Pre-Existing Conditions are not covered.

4. any premium due date, if premium remains unpaid by the During the first 12 months following the date a Covered Person end of the grace period. makes a change in coverage that increases his or her benefits, 5. the premium due date coinciding with or next following the increase will not be paid for Pre-Existing Conditions. After the date the Covered Person ceases to be a member of an this 12 month period, however, benefits for such conditions eligible class. will be payable unless specifically excluded from coverage. This 6. the date the Policyholder no longer meets participation 12 month period is measured from the Certificate Effective requirements.

Date for each Covered Person.

Pre-Existing Condition means Cancer or a Specified Disease, for Portability which a Covered Person has received medical consultation, On the date the Policy terminates or the date the Named treatment, care, services, or for which diagnostic test(s) have Insured ceases to be a member of an eligible class, Named been recommended or for which medication has been Insureds and their covered dependents will be eligible to prescribed during the 12 months immediately preceding the exercise the portability privilege. Portability coverage may Certificate Effective Date of coverage for each Covered Person. continue beyond the termination date of the Policy, subject to the timely payment of premiums. Portability coverage will be Exceptions and Other Limitations effective on the day after insurance under the Policy The Policy pays benefits only for diagnoses resulting from terminates.

Cancer or Specified Diseases, as defined in the Policy. It does The benefits, terms and conditions of the portability coverage not cover: will be the same as those provided under the Policy when the 1. any other disease or sickness; insurance terminated. The initial portability premium rate is 2. injuries; the rate in effect under the Policy for active employees who 3. any disease, condition, or incapacity that has been caused, have the same coverage. The premium rate for portability complicated, worsened, or affected by: coverage may change for the class of Covered Persons on a. Specified Disease or Specified Disease treatment; portability on any premium due date. or b. Cancer or Cancer treatment, or unless otherwise defined in the Policy 4. care and treatment received outside the United States or its territories; 5. treatment not approved by a Physician as medically necessary; 6. Experimental Treatment by any program that does not qualify as Experimental Treatment as defined in the Policy.

Cancer Covered Persons Covered Person means any of the following: a. the Named Insured; or b. any eligible Spouse or Child, as defined and as indicated on the Certificate Schedule whose coverage has become effective; c. any eligible Spouse or Child, as defined and added to this Certificate by endorsement after the Certificate Effective Date whose coverage has become effective; or d. a newborn child (as described in the Eligibility Section).

Step Down Unit We will pay a benefit equal to one half the chosen daily benefit for confinement in a Step Down Unit.

Exceptions and Other Limitations Except as provided in Step Down Unit and Emergency Hospitalization and Subsequent Transfer to an ICU, coverage does not provide benefits for: surgical recovery rooms; progressive care; intermediate care; private monitored rooms; observation units; telemetry units; or other facilities which do Child (Children) means the Named Insured’s unmarried child, not meet the standards for a Hospital Intensive Care Unit. including a natural child from the moment of birth, stepchild, Benefits are not payable: if you go into an ICU before the foster or legally adopted child, or child in the process of adoption (including a child while the Named Insured is a party to Certificate Effective Date; if you go into an ICU for intentionally a proceeding in which the adoption of such child by the Named self-inflicted bodily injury or suicide attempts; if you go into an ICU due to being intoxicated or under the influence of alcohol, Insured is sought); a child for whom the Named Insured is drugs or any narcotics, unless administered on the advice of a required by a court order to provide medical support, and Physician and taken according to the Physician’s instructions. grandchildren who are dependent on the Named Insured for The term “intoxicated” refers to that condition as defined by law federal income tax purposes at the time of application, who is: in the jurisdiction where the accident or cause of loss occurred. a. not yet age 25; or b. not yet age 26 if a full time student at an accredited school.

Option To Add Additional Benefits Hospital Intensive Care Insurance Rider Form Number HIC-GP-ICR 6/09 In consideration of additional premium, this coverage will provide you with benefits if you go into a Hospital Intensive Care Unit (ICU).

Benefits Your benefits start the first day you go into ICU. The benefit is payable for up to 45 days per ICU stay.

Hospital Intensive Care Confinement Benefit You may choose the benefit of $325 or $625 per day. It is reduced by one-half at age 75.

Double Benefits We will double the daily benefits for each day you are in an ICU as a result of Cancer or a Specified Disease. We will also double the benefit for an injury that results from: being struck by an automobile, bus, truck, motorcycle, train, or airplane; or being involved in an accident in which the named insured was the operator or was a passenger in such vehicle. ICU confinement must occur within 48 hours of the accident.

Emergency Hospitalization and Subsequent Transfer to an ICU We will pay the benefit selected by you for the highest level of care in a hospital that does not have an ICU, if you are admitted on an emergency basis, and you are transferred within 48 hours to the ICU of another Hospital.

Cancer

AUL a ONEAMERICA COMPANY 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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

Life and AD&D For New Hires  The enrollment takes place within 31 days from the date Employee Coverage you become eligible for benefits, and $10,000 increments to a maximum of $500,000.  You are enrolling your spouse for coverage equal to/less Dependent Coverage than $50,000.

You must be enrolled in voluntary employee life benefits to be If you do not meet all of the conditions stated above, you will eligible for benefits on your dependent(s) Spouse - $5,000 increments to a maximum of the lesser of 100% need to provide additional medical information by completing a Statement of Health form. of your Life Benefits or $500,000.

Supplemental Term Life

Dependent Children - $10,000. *Child(ren)’s Eligibility: Dependent children ages from live birth to 26 years old are eligible for coverage Guarantee Increase of Benefit : If eligible, this benefit allows you to increase your coverage every year as your life insurance needs change. You may increase your benefit amount by $10,000, and your spouse by $5,000 every year until you reach your maximum amount, without providing Evidence of Insurability.

For New Hires:  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 7 times your basic annual earnings or $250,000 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.

Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & Over Cost for your Child (ren)*

EE Cost per $10,000

Spouse Cost per $10,000

$0.63 $0.63 $0.63 $0.92 $1.37 $2.08 $3.17 $5.12 $6.80 $11.55 $20.53 $1.50

$0.63 $0.63 $0.63 $0.92 $1.37 $2.08 $3.17 $5.12 $6.80 $11.55 $20.53

For Annual Enrollment The enrollment takes place prior to the enrollment deadline, and Your spouse and child(ren) are enrolling for coverage only one increment more than their current coverage

Voluntary AD&D Employee Coverage  Increments of $10,000 The maximum amount of coverage you can receive is $500,000.

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 Spouse and Child(ren):  Spouse — 50% of your coverage amount  Child(ren) — 10% of your coverage amount What Is Not Covered?

Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.

AD&D Supplemental Coverage

Monthly Cost per $10,000

Employee

$0.21

Employee & Family

$0.51

VOYA 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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

Accident What accident benefits are available?

The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your injury within a set amount of time.

Note that there may be some variations by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.

EVENT Accident Hospital Care Surgery Open abdominal, thoracic Surgery exploratory or without repair Blood, plasma, platelets Hospital admission Hospital confinement Per day up to 365 Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day for 90 days Coma Duration of 14 or more days Transportation per trip, up to 3 per accident Lodging Per day, up to 30 days Family care per child, up to 45 days Follow Up Care Medical equipment Physical therapy per treatment, up to 6 Prosthetic device (one) Prosthetic device (two or more)

LOW

HIGH

$1,200

$2,500

$120

$250

$360 $1,000

$400 $1,400

$250

$300

$500

$600

$150

$175

$6,000

$7,000

$360

$400

$120

$150

$25

$30

$120 $30 $600 $1,200

$250 $50 $1,200 $2,400

$900

$1250

Common Injuries

Burns second degree, at least 36% of the body Burns 3rd degree, at least 9 but less than 35 square inches of the body Burns 3rd degree, 35 or more square inches of the body Skin Grafts Emergency dental work while hospital confined Eye Injury removal of foreign object Eye Injury surgery Torn Knee Cartilage surgery with no repair or if cartilage is shaved Torn Knee Cartilage surgical repair Laceration1 treated no sutures Laceration1 sutures up to 2” Laceration1 sutures 2” – 6” Laceration1 sutures over 6” Ruptured Disk surgical repair Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff Two or more, surgical repair Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with no repair Concussion Paralysis quadriplegia Paralysis paraplegia

$1,800

$2,500

$12,000

$18,000

25% of burn benefit

25% of burn benefit

$180 crown, $60 extraction $60

$250 crown, $125 extraction $75

$240 $120 $600 $30 $60 $240

$300 $150 $750 $60 $120 $480

$480

$960

$480 $480

$600 $600

$720

$900

$120

$200

$120

$250

$12,000

$15,000

$6,000

$7500

Accident EVENT

LOW

HIGH

Dislocations

Closed/open reduction2

Closed/open reduction2

Hip joint Knee Ankle or foot bone(s) Other than toes Shoulder Elbow Wrist Finger/toe Hand bone(s) Other than fingers Lower jaw Collarbone Partial dislocations Fractures Hip Leg Ankle Kneecap Foot Excluding toes, heel Upper arm Forearm, Hand, Wrist Except fingers Finger, Toe Vertebral body Vertebral processes Pelvis Except coccyx Coccyx Bones of face Except nose Nose Upper jaw Lower jaw Collarbone Rib or ribs Skull – simple Except bones of face Skull – depressed Except bones of face

$2,400/$4,800 $1,200/$2,400 $960/$1,920 $360/$720 $360/$720 $360/$720

$2,500/$5,000 $1,500/$3,000 $1,200/$2,400 $500/$1,000 $500/$1,000 $500/$1,000

$120/$240 $360/$720 $360/$720 $360/$720

$150/$300 $500/$1,000 $500/$1,000 $500/$1,000

25% of closed reduction

25% of closed reduction

Closed/open reduction3

Closed/open reduction3

$1,800/$3,600 $960/$1,920 $360/$720 $360/$720 $360/$720 $420/$840

$2,500/$5,000 $1,250/$2,500 $500/$1,000 $500/$1,000 $500/$1,000 $550/$1,100

$360/$720 $60/$120 $960/$1,920 $360/$720 $960/$1,920 $240/$480

$500/$1,000 $100/$200 $1,200/$2,400 $500/$1,000 $1,200/$2,400 $350/$700

$420/$840 $120/$240 $420/$840 $360/$720 $360/$720 $300/$600

$550/$1,100 $150/$300 $550/$1,100 $500/$1,000 $500/$1,000 $450/$900

$1,200/$2,400 $3,000/$6,000 $360/$720 $360/$720 25% of closed reduction amount

$1,500/$3,000 $5,000/$10,000 $500/$1,000 $500/$1,000 25% of closed reduction amount

Ground ambulance

$120

$200

Air ambulance

$600

$1000

Emergency room treatment

$180

$300

Initial doctor visit

$60

$80

Follow-up doctor visit

$60

$80

Sternum Shoulder blade Chip fractures Emergency care benefits

1

Laceration benefits are a total of all lacerations per accident.

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

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

2

Accident What does my Accident Insurance include?

Exclusions and limitations

The benefits listed below are included with your Accident Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.  Sports Accident Benefit: If your accident occurs while participating in an organized sporting activity as defined in the certificate; the accident hospital care, accident care or common injuries benefit will be increased by 25%; to a maximum additional benefit of $1000.  Accidental Death and Dismemberment (AD&D) coverage: If you are severely injured or die as a result of a covered accident, an AD&D benefit may be payable to you or your beneficiary.  Common carrier: If the death occurs as a result of a covered accident on a common carrier, a higher benefit will be payable. Common carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined points or cities.

Exclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance and AD&D are listed below.

(These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*:  Participation or attempt to participate in a felony or illegal activity.  An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred.  Suicide, attempted suicide or any intentionally selfinflicted injury, while sane or insane.  War or any act of war, whether declared or undeclared, other than acts of terrorism.  Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.  Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.  Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.  Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded. Performing these acts as part of your employment with the employer is not excluded.  Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities.  Practicing for, or participating in, any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received.  Any sickness or declining process caused by a sickness.  Work for pay, profit or gain.

Accidental Death Benefits Employee Spouse Children Other Accident Employee Spouse Children Accidental Dismemberment Benefits Loss of both hand or both feet or sight in both eyes Loss of one hand or one foot AND the sight of one eye Loss of one hand AND one foot Loss of one hand OR one foot Loss of Two or more fingers or toes Loss of one finger or one toe

Low $60,000 $24,000 $12,000

High $120,000 $48,000 $24,000

$30,000 $12,000 $6,000 Low

$60,000 $24,000 $12,000 High

$18,000

$25,000

$18,000

$25,000

$18,000 $9,000

$25,000 $12,000

$1,800

$2,500

$900

$1,200

How much does Accident Insurance cost?

All employees pay the same rate, no matter their age. See the chart below for the premium amounts. Rates shown are guaranteed until September 2020.

Employee $10.38

Employee $16.01

Low Option Monthly Rates Employee Employee and Spouse and Children $16.96

$19.50

High Option (Monthly Rates Employee Employee and Spouse and Children $25.93

$29.64

Family $26.08

Family $39.56

*See the certificate of insurance and riders for a complete list of available benefits, exclusions and limitations.

RELIANCE STANDARD

Critical Illness

YOUR BENEFITS PACKAGE

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

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

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

Critical Illness Scheduled Benefit: Each eligible employee may elect for himself and/or his eligible spouse an amount of insurance shown in the table below.

Employee/Spouse Premiums: To find you and your spouse's premium  Determine your age band:  Your age = your age at your last birthday.  Spouse age = employee age.  For employees age 70 or older, benefit amounts are reduced according to the agebased reduction chart shown in the Plan Highlights. When selecting an amount of insurance, you must select at pre-age 70 benefit amount.  Select a benefit from:  Select an employee and spouse benefit from the table below.  Employee and spouse rates change as insured moves from one age bracket to the next, based on the age determination rules.

Dependent Child(ren): Your dependent child(ren) is eligible for a benefit amount of 25% of your Critical Illness benefit election, limited to a maximum of $12,500.

To calculate Dependent Child(ren) Benefit: Employee Benefit Amount x 25% = Dependent Child(ren) Benefit. No rounding needed.

To calculate Dependent Child(ren) Premium: Dependent Child(ren) Benefit/1000 x 0.145.

Please Note: One rate and benefit amount for all eligible children in family, regardless of number.

Please read this important information You may not have coverage as both an employee and as a dependent.

Employee must have coverage in order for spouse and dependent children to be covered.

Employee Semi-Monthly Premiums Age Benefit Age 0-29 30-34 Amount

Age 35-39

Age 40-44

Age 45-49

Age 50-54

Age 55-59

Age 60-64

Age 65-69

Age 70-74

Age 75-79

Age Age 85+ 80-84

$5,000

$0.90

$1.25

$1.53

$2.18

$3.30

$4.83

$6.40

$8.90

$12.53

$15.98

$21.33

$26.48

$41.95

$10,000

$1.80

$2.50

$3.05

$4.35

$6.60

$9.65

$12.80

$17.80

$25.05

$31.95

$42.65

$52.95

$83.90

$15,000

$2.70

$3.75

$4.58

$6.53

$9.90

$14.48

$19.20

$26.70

$37.58

$47.93

$63.98

$79.43

$125.85

$20,000

$3.60

$5.00

$6.10

$8.70

$13.20

$19.30

$25.60

$35.60

$50.10

$63.90

$85.30

$105.90 $167.80

$25,000

$4.50

$6.25

$7.63

$10.88

$16.50

$24.13

$32.00

$44.50

$62.63

$79.88

$106.63 $132.38 $209.75

$30,000

$5.40

$7.50

$9.15

$13.05

$19.80

$28.95

$38.40

$53.40

$75.15

$95.85

$127.95 $158.85 $251.70

$35,000

$6.30

$8.75

$10.68

$15.23

$23.10

$33.78

$44.80

$62.30

$87.68

$111.83 $149.28 $185.33 $293.65

$40,000

$7.20

$10.00

$12.20

$17.40

$26.40

$38.60

$51.20

$71.20

$100.20 $127.80 $170.60 $211.80 $335.60

$45,000

$8.10

$11.25

$13.73

$19.58

$29.70

$43.43

$57.60

$80.10

$112.73 $143.78 $191.93 $238.28 $377.55

$50,000

$9.00

$12.50

$15.25

$21.75

$33.00

$48.25

$64.00

$89.00

$125.25 $159.75 $213.25 $264.75 $419.50

TEXAS LIFE

Individual Life

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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

Individual Life Life Insurance Highlights Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit.

The policy, PureLife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: 

High Death Benefit. With one of the highest death benefit available at the worksite,1 PureLife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.



Minimal Cash Value. Designed to provide high death benefit, PureLife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans.



Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up).



Refund of Premium. Unique in the marketplace, PureLife-plus offers you a refund of 10 years’ premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)



Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.)

You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren.

Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details.

1

Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008

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

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.

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

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

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

You may use the card to pay merchants or service providers who accept MasterCard® credit cards, so there is no need to pay cash up-front and then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you throw away your cards, there is a $5.00 fee to replace them.

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB mid-September.

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

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

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

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

FSA Annual Contribution Max: $2,600

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status Health Care and Dependent Care Account balances Claim forms, direct deposit form, worksheets, etc.

Online claim FAQs

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

FSA Frequently Asked Questions What is a Flexible Spending Account?

A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses and dependent care expenses. You may save as much as 35 percent on the cost of each benefit option!

Eligible expenses must be incurred within the plan year and contributions are use-it-or-lose-it. Remember to retain all your receipts.

Health Care Expense Account Example Expenses:          

Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid

        

Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers

Dependent Care Expense Account Example Expenses:    

Before and After School and/or Extended Day Programs The actual care of the dependent in your home Preschool tuition The base costs for day camps or similar programs used as care for a qualifying individual

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenefitshub.com/southsideisd

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

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

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

How Do I File A Claim?

In most situations, you will be able to swipe your card.

However, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/southsideisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

How To Receive Your Dependent Care Reimbursement Faster.

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

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

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

Get Your Money 1.

2.

3.

4.

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

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

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

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

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

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

DEER OAKS

EAP (Employee Assistance Program)

YOUR BENEFITS PACKAGE

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

38%

of employees have missed life events because of bad worklife balance.

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

Employee Assistance Program (EAP) The Deer Oaks Employee Assistance Program (EAP) is a free service provided for you and your dependents by your employer. This program offers a wide variety of counseling, referral, and consultation services, which are all designed to assist you and your family in resolving work/life issues in order to live happier, healthier, more balanced lives. These services are completely confidential and can be easily accessed by calling the toll-free Helpline.

Below is an overview of the services available through your EAP: Eligibility: All employees and their household members/ dependents are eligible to access the EAP. This includes retirees and employees who have recently separated from their employer.

Assessment & Counseling: A network of 54,000+ mental health providers throughout the United States is available to provide in-person assessment and counseling services to members wherever they may reside. Counselors may also conduct comprehensive assessments by phone and provide in-themoment telephonic support and crisis intervention.

Tele-Language Services: Deer Oaks has the ability to provide therapy in a language other than English if requested. Services are available for telephonic interpretation in over 190 of the most commonly spoken languages and dialects.

Referrals & Community Resources: Counselors provide referrals to community resources, member health plans, support groups, legal resources, and child/elder care services.

Advantage Legal Assist: Free 30-minute telephonic consultation with a plan attorney; free 30-minute in-person consultation; 25% discount on hourly attorney fees if representation is required; unlimited online access to a wealth of educational legal resources, links, tools and forms; interactive online Simple Will preparation; access to state agencies to obtain birth certificates and other records.

Advantage Financial Assist: Unlimited telephonic consultation with a financial counselor qualified to advise on a range of financial issues such as bankruptcy prevention, debt reduction and financial planning; supporting educational materials available; credit report review by a financial counselor and tips for improvement; objective, pressure-free advice; unlimited online access to a wealth of educational financial resources, links, tools and forms (i.e. tax guides, financial calculators, etc.).

Interactive Online Simple Will Preparation: Create a legallybinding simple state specific will at no cost through a step by step online "interview process." Access this service through www.deeroaks.com

Credit Monitoring: Free credit reports and credit monitoring available via the legal/financial center ID Recovery: Free 30-minute telephonic consultation with an Identity Recovery Professional; customized action plan and consultation; ongoing ID recovery guidance available as needed; free ID monitoring service.

Monthly Electronic Newsletters: Employees and supervisors receive monthly e-newsletters covering a variety of topics including health and wellness, work/life balance issues, conflict resolution, leadership, and more.

Online Tools & Resources: Log on to www.deeroaks.com to access an extensive topical library containing health and wellness articles, child and elder care resources, work/life balance resources and webinars. Contact (866)327-2400 / eap@deeroaks.com Work/Life Services: Work/Life Consultants are available to assist members with a wide range of daily living resources such as pet sitters, event planners, home repair, tutors and moving services. Simply call the Helpline for resource and referral information.

Find-Now Child & Elder Care Program: This program assists participants caring for children and/or aging parents with the search for licensed, regulated, and inspected child and elder care facilities in their area. Work/Life Consultants assess each member's needs, provide guidance, resources, and a list of up to three (3) referrals within 12 hours of the call. Searchable databases and other resources are also available on the Deer Oaks website.

Health & Wellbeing: Deer Oaks encourages not only the mental health, but also the physical health and wellbeing of our members. Work/Life Consultants are available to provide referrals to providers, specialists, and resources to meet specific needs such as safety programs, support groups, fitness centers and nutrition programs.

Critical Incident Stress Management: Traumatic events can be extremely disruptive to the well-being and productivity of employees. Deer Oaks will respond quickly when asked to provide Critical Incident Stress Management Services for any major company incident.

Take the High Road: Deer Oaks reimburses members for their cab fares in the event that they are incapacitated due to impairment by a substance or extreme emotional condition.

This service is available once per year per participant with a maximum reimbursement of $45.00 (excludes tips).

SPECIAL INSURANCE SERVICES

YOUR BENEFITS PACKAGE

Medical Gap Insurance

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

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

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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

Medical Gap Insurance Basic Plan Benefits offered to employees of Southside ISD SecureADVANTAGE is designed to complement your existing major medical insurance and provide added coverage that fills the gaps between what your major medical plan will pay and what you owe out of your own pocket if you are hospital confined. It provides added coverage for you and each covered family member, should you be required to pay for expenses associated with each hospital confinement that are applied to your deductible and coinsurance. Benefits are paid directly to you when you are hospitalized due to an injury or sickness, unless an Assignment of Benefits Form dictates that benefits should be paid to your doctor or the hospital at time of treatment.

Inpatient Services SecureADVANTAGE pays covered expenses for:  In-Patient Hospital stays  In-Patient Surgeries  In-Patient Tests, Procedures, and Medications (billed through the facility)  Physician In-Hospital charges  Emergency Room treatment for Injuries and Sickness (sickness must result in hospital confinement within 24 hours of ER treatment)

Outpatient Services SecureADVANTAGE pays covered expenses including but not limited to:  Hospital Emergency Room Treatment for Injury or Sickness  Outpatient surgery in an outpatient Surgical Facility, Emergency Facility or Physician’s Office  Diagnostic Testing including Xrays, Diagnostic Lab, MRI’s and CT scans  Outpatient Chemotherapy or Radiation Therapy  Physical Therapy or Chiropractic Care

Outpatient Benefits: The Outpatient I Benefit pays on a per person per Sickness or Injury basis, up to a maximum of four "occurrences" per family per calendar year. This maximum applies to the entire family unit, regardless of the number of covered persons within the family unit. An "occurrence" is the treatment, or series of treatments, for a specific Sickness or Injury. All expenses related to the treatment of the same related Sickness or Injury will accrue toward the outpatient maximum for one occurrence, regardless of whether such treatment is received in more than one calendar year period. If, however, a Covered Person is treatment-free, at any time, for at least 90 consecutive days, they may qualify for an additional outpatient maximum benefit if the family maximum per calendar year has not been met.

Secure Advantage Outpatient Benefits I pays for covered expenses including but not limited to :     

Hospital Emergency Room Treatment for Injury or Sickness Outpatient Surgery in an outpatient surgical facility, emergency facility or physician’s office Diagnostic testing including but not limited to Xrays, diagnostic lab, MRI’s and CT scans Outpatient chemotherapy or radiation therapy Physical therapy or chiropractic care All Inpatient and Outpatient Benefits are limited to those expenses that are medically necessary for the treatment of an Injury or Sickness. Further, such expenses must be covered under the major medical comprehensive policy and applied to that plans deductible, copayment, or coinsurance provision.

Hospital Confinement Covers expenses associated with deductible, co-pay and coinsurance amounts not covered by your major medical plan.

Outpatient Covers expenses associated with deductible, co-pay and coinsurance amounts not covered by your major medical plan.

Option 1

Option 2

Up to $1,000.00

Up to $4,500.00

Up to $1,000.00

Up to $2,500.00

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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

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

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

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

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

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

Who are our doctors?

MDLIVE has the nation’s largest network of telehealth doctors.

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

Are children eligible?

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

How much does it cost? $12.00 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

Scan with your smartphone to get the app.

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

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

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 Southside ISD Benefits Website: www.mybenefitshub.com/southsideisd

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.

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

NO health questions for employee/spouse children covered to age 26 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

How Much Does It Cost?

You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill.

EMERGENT $9/mo.

(30% off)

EMERGENT Semi-Monthly $4.50 (30% off)

Emergency Air Medical Transport

✔

✔

Emergency Ground Ambulance Transport

✔

✔

BENEFIT We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short.

“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

WWW.MYBENEFITSHUB.COM/ SOUTHSIDE