2019 Benefit Guide Los Fresnos CISD

LOS FRESNOS CISD

BENEFIT GUIDE EFFECTIVE: 01/01/2019 - 12/31/2019 WWW.MYBENEFITSHUB.COM/ LOSFRESNOSCISD

1

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) BCBSTX Medical and Pharmacy Plans BCBSTX Dental Superior Vision The Hartford Disability APL Cancer VOYA Critical Illness The Hartford Accident AUL a OneAmerica Company Life and AD&D ï‚· Compsych EAP NBS Flexible Spending Account MASA Medical Transport

2

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

FLIP TO...

PG. 4 HOW TO HOW TO ENROLL ENROLL

11 12-23 24-25 26-27 28-29 30-35 36-37 38-39 40-42 43 44-47 48-49

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information BENEFIT ADMINISTRATORS

VISION

FLEXIBLE SPENDING ACCOUNT

Financial Benefit Services Superior Vision (800) 583-6908 (800) 507-3800 www.mybenefitshub.com/losfresnoscisd www.superiorvision.com

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

MEDICAL

DISABILITY

MEDICAL TRANSPORT

Group #028371 Blue Cross Blue Shield (800) 521-2227 www.bcbstx.com

The Hartford (866) 278-2655 www.thehartfordatwork.com

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

CANCER

DENTAL

EMPLOYEE ASSISTANCE PROGRAM

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

Group #029511 Blue Cross Blue Shield (800) 521-2227 www.bcbstx.com

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

LIFE AND AD&D

ACCIDENT

CRITICAL ILLNESS

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

The Hartford (866) 278-2655 www.thehartfordatwork.com

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

3

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet.

Text “FBS LFCISD” to 313131 and get access to everything you

Text

need to complete your benefits

“FBS LFCISD” to 313131

enrollment: 

Benefit Information



Online Support



Interactive Tools



And more.

PLAY VIDEO

4

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/losfresnoscisd

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 lowercase, followed by the first letter of your first name, followed by the last four (4) numbers of your

ONLINE SUPPORT

Social Security Number.

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) numbers of your Social Security Number.

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

5

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.

losfresnoscisd. 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 benefit website: www.mybenefitshub.com/

included in the dependent profile. Additionally, you must

losfresnoscisd. Click on the benefit plan you need information

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



For benefit summaries and claim forms, go to 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.

on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

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

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

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

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

Q&A Who do I contact with Questions?

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

6

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 Los Fresnos CISD 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

BCBSTX

To age 26

Telehealth

MDLIVE

To age 26

Dental

BCBSTX

To age 26

Vision

Superior Vision

To age 26

Disability

The Hartford

To age 26

Cancer

American Public Life

To age 26

Life & AD&D

OneAmerica

To age 26

Flexible Spending Account

NBS

To age 26

Medical Transportation

MASA

To age 26

Critical Illness

VOYA

To age 26

Accident

The Hartford

To age 26

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

7

Annual Benefit Enrollment Benefit Updates - What’s New: 

Financial Benefit Services (FBS) is pleased to have been chosen as the new Agent of Record for your voluntary benefits. We would also like to introduce your new online enrollment system, THEBenefitsHUB. Please take advantage of the simple process to complete your enrollment for the upcoming 2019 plan year. If you are declining coverages, please log in and confirm your choices.



We will be having a Passive Enrollment this year, however if you are declining coverages or re-electing the Flexible Savings Account, you will need to still complete the enrollment and waive all necessary coverages on THEBenefitsHUB.

Don’t Forget!

Social Security Numbers for your dependents are required regardless if they are enrolled in coverage or not. Please make sure you have these items on hand when going through your open enrollment.

Important Enrollment assistance is available by calling Financial Benefit Services at (800) 583-6908 to speak to a representative. Spanish speaking representatives are also available.

Annual Open Enrollment Benefit elections will become effective 01/01/2019 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 31 days of event).

8

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 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

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

9

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 01/01/2019 please notify your benefits administrator.

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

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

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

Plan Year January 1st through December 31st

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

Calendar Year January 1st through December 31st

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

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

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

10

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

Description

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

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Employer

Minimum Deductible

N/A

Maximum Contribution

$2700

Permissible Use Of Funds

Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

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

Not permitted

Year-to-year rollover of account balance?

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?

No

Portable?

No

None

FLIP TO FOR FSA INFORMATION

PG. 44

11

Basic Medical Plan Plan Provisions Deductibles  Per- admission Deductible 

Calendar Year Deductible Three- month Deductible carryover applies Applies to all Eligible Expenses Co-Share Stop-Loss Amounts (Includes Calendar Year Deductible and Copayment Amounts)

In-Network Benefits

Out-of-Network Benefits

None

$200 per- admission Deductible

$1,200 – per individual

$3,600 – per individual

$3,600 – per family

$7,200 – per family

$6,000 – per individual

$9,000 – per individual

$12,000 – per family

$24,000 – per family

Copayment Amounts Required $45 Physician office visit  Physician office visit/consultation for Primary Care Providers $50 Physician office visit  Physician office visit/consultation for Specialty Care Providers  Outpatient Hospital Emergency Room/Treatment $150 outpatient Hospital Emergency Room/Treatment Room visit Room visit $60 Urgent Care Center visit  Urgent Care Center visit 

Retail Health Clinic

Does Not Apply Does Not Apply $150 outpatient Hospital Emergency Room/Treatment Room visit Does Not Apply

$45 Retail Health Clinic visit

Does Not Apply

70% of Allowable Amount after Calendar Year Deductible No penalty for failure to Preauthorize services

50% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible $250 penalty for failure to Preauthorize services

100% of Allowable Amount after $45 Copayment Amount 100% of Allowable Amount after $50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

Inpatient Hospital Expenses All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.

Medical-Surgical Expenses  Office visit/consultation, (Primary Care Providers) including Lab and X- Rays  Office visit/consultation, (Specialty Care Providers) including Lab and X- Rays  Radiation Therapy and Chemotherapy in the office setting  Diabetic Management (training/nutritional)  Inpatient visits  Certain Diagnostic Procedures  Home Infusion Therapy  Physician surgical services in any setting  Allergy Injections (without office visit) 

Independent Lab and X-Ray



Services and supplies provided by Digi-Rad X-Ray Mobile  Services and supplies provided by Los Fresnos Medicine Clinic and Rio Hondo Medicine Clinic Extended Care Expenses

100% of Allowable Amount up to a $60 maximum 100% of Allowable Amount after $10 Copayment Amount

90% of Allowable Amount after Calendar Year Deductible 

Skilled Nursing Facility

60 days combined Calendar Year maximum



Home Health Care

60 visits combined Calendar Year maximum



Hospice Care 12

Unlimited

Basic Medical Plan Plan Provisions

In-Network Benefits

Out-of-Network Benefits

Mental Health Care, Serious Mental Illness, and Treatment of Chemical Dependency (Certain Services will require Preauthorization) Inpatient Services 

Hospital Services (facility)

70% of Allowable Amount after Calendar Year Deductible



Behavioral Health Practitioner Services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $45 Copayment Amount 70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

Outpatient Services 

Behavioral Health Practitioner Expenses (office setting)



Other Outpatient Services

Emergency Care Accidental Injury & Emergency Care (including Accidental Injury & Emergency Care for Behavioral Health Services) 

Facility Charges



Lab & X- Ray - without emergency room or treatment room



Physician Charges

70% of Allowable Amount after $150 outpatient Hospital emergency room Copayment Amount (waived if admitted) 100% of Allowable Amount 70% of Allowable Amount after Calendar Year Deductible

Non-Emergency Care (including Non-Emergency Care for Behavioral Health Services)



Facility Charges



Physician Charges

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after $150 outpatient Hospital emergency room Copayment Amount (waived if admitted) and after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $60 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

70% of Allowable Amount after $150 outpatient Hospital emergency room Copayment Amount (waived if admitted)

Urgent Care Services Urgent Care Center visit - including Lab & X- Ray services (excluding Certain Diagnostic Procedures) Ambulance Services Retail Health Clinic

70% of Allowable Amount after Calendar Year Deductible 100% of Allowable Amount after $45 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

Preventative Care Services 





Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”) for infants, children, and adolescents

13

Basic Medical Plan Plan Provisions Preventive Care Services (Cont'd)  With respect to women, such additional preventive care and screenings, not described in the first bullet above, as provided for in comprehensive guidelines supported by the HRSA  Routine physical examinations, well baby care, immunizations, and routine Lab  Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures (Independent Lab & X- Ray Provider)  Colonoscopy, Physician and facility charges  Healthy diet counseling and obesity screening/ counseling 

Childhood immunizations

In-Network Benefits

Out-of-Network Benefits

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

100% of Allowable Amount

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

Other Routine Services 

Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures

 

Annual Hearing Examination Annual Vision Examination

Speech and Hearing Services 

Office visit

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible



All other services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible

1 per ear per 36- month period for hearing aids Chiropractic Services (35 visits maximum per Calendar Year) 

Office visit

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible



All other services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible



Airrosti Provider

35 visits combined per Calendar Year maximum for above 100% of Allowable Amount after Does Not Apply $45 Copayment Amount 35 visits maximum per Calendar Year

Physical Medicine Services (35 visits maximum per Calendar Year) 

Office visit/Office services

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible



All other outpatient services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible

14

Basic Medical Pharmacy Benefits Plan Provisions

Participating Pharmacy

Non-Participating Pharmacy

Retail Pharmacy 90 day supply with 1 Copayment Amount per 30-day supply at a Participating Pharmacy 

Generic Drugs



Preferred Brand Name Drugs



Non- Preferred Brand Name Drugs

$0 Copayment Amount $30 Copayment Amount* or 30% of Allowable Amount, whichever is greater $30 Copayment Amount* or 30% of Allowable Amount, whichever is greater Specialty Pharmacy Provider $100 Copayment Amount* Specialty Drugs

Specialty Pharmacy Program Specialty Drugs- limited to a 30-day supply at a Specialty Pharmacy Provider Mail-Order Program One Copayment Amount per 90 day supply, up to a 90-day supply only 

Generic Drugs



Preferred Brand Name Drugs

$70 Copayment Amount*



Non- Preferred Brand Name Drugs

$100 Copayment Amount*

80% of Allowable Amount minus Copayment Amount 80% of Allowable Amount minus Copayment Amount 80% of Allowable Amount minus Copayment Amount Not Covered

$0 Copayment Amount Not Covered

Select Participating Pharmacy 100% of Allowable Amount Select Vaccinations Obtained through Participating 80% of Allowable Amount minus Any other Participating Pharmacy 80% Pharmacies** Copayment Amount of Allowable Amount minus Copayment Amount Prior Authorization Provision Applies Step Therapy Provision Applies Limitations on Quantities Dispensed Applies Diabetes Supplies are available under the Pharmacy Benefits portion of your Plan. All provisions of this portion of the Plan Prescribed and over- the- counter will be paid under the Generic Copayment level, prescription would be needed to apply the generic Copayment Amount at the time of purchase.

Tobacco cessation drugs (including both prescription and over- the- counter drugs) prescribed by a Health Care Practitioner are covered at no cost share and will not be subject to Deductibles, Copayment Amounts and Co- Share Amounts for two 90- day treatment regimens per benefit period as required by the United States Preventive Services Task Force as referenced in the Preventive Care section of the PHARMACY BENEFITS portion of the Plan.

Contraceptive drugs and devices obtained from a Participating Pharmacy that are identified on the BCBSTX website under Contraceptive - Pharmacy information (referenced in the medical portion of the Plan as part of Benefits for Preventive Care Services) will not be subject to Deductibles, Copayment Amounts, and Co- Share Amounts.

Additional contraceptive drugs and contraceptive devices are covered under the Pharmacy portion of the Plan and are subject to the applicable Copayment Amounts, Co- Share Amounts, and any pricing differences. * If you receive a Preferred Brand Name Drug or a Non- Preferred Brand Name Drug when a Generic Drug is available, you may incur additional costs. Refer to the Pharmacy Benefits portion of this Benefit Booklet for details. ** Select Participating Pharmacies that have contracted with BCBSTX to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Vaccinations at all other pharmacies (participating and non- participating) will be payable at the non- participating benefit level. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. A Select Participating Pharmacy is a Pharmacy that has specifically contracted with BCBSTX to administer vaccinations to Participants.

Not all Participating Pharmacies are Select Participating Pharmacies.

NOTE: In the How Member Payment is Determined subsection of the PHARMACY BENEFITS section, an explanation of how the prescription drug products are separated into tiers is shown.

Dependent Eligibility Dependent Child Age Limit to age 26.

Dependent children are not eligible for Maternity Care Preexisting Conditions Preexisting conditions are covered immediately.

15

School Medical Plan Plan Provisions Deductibles  Per- admission Deductible 

Calendar Year Deductible Three- month Deductible carryover applies Applies to all Eligible Expenses Co-Share Stop-Loss Amounts (Includes Calendar Year Deductible and Copayment Amounts)

In-Network Benefits

Out-of-Network Benefits

None

$200 per- admission Deductible

$1,000 – per individual

$3,000 – per individual

$3,000 – per family

$6,000 – per family

$5,000 – per individual

$7,500 – per individual

$10,000 – per family

$18,000 – per family

Copayment Amounts Required $35 Physician office visit  Physician office visit/consultation for Primary Care Providers $40 Physician office visit  Physician office visit/consultation for Specialty Care Providers $125 outpatient Hospital Emergency  Outpatient Hospital Emergency Room/Treatment Room/Treatment Room visit Room visit $50 Urgent Care Center visit  Urgent Care Center visit 

Retail Health Clinic

Does Not Apply Does Not Apply $125 outpatient Hospital Emergency Room/Treatment Room visit Does Not Apply

$35 Retail Health Clinic visit

Does Not Apply

80% of Allowable Amount after Calendar Year Deductible No penalty for failure to Preauthorize services

60% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible $250 penalty for failure to Preauthorize services

100% of Allowable Amount after $35 Copayment Amount 100% of Allowable Amount after $40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

Inpatient Hospital Expenses All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.

Medical-Surgical Expenses  Office visit/consultation, (Primary Care Providers) including Lab and X- Rays  Office visit/consultation, (Specialty Care Providers) including Lab and X- Rays  Radiation Therapy and Chemotherapy in the office setting  Diabetic Management (training/nutritional)  Inpatient visits  Certain Diagnostic Procedures  Home Infusion Therapy  Physician surgical services in any setting  Allergy Injections (without office visit) 

Independent Lab and X-Ray



Services and supplies provided by Digi-Rad X-Ray Mobile  Services and supplies provided by Los Fresnos Medicine Clinic and Rio Hondo Medicine Clinic Extended Care Expenses

100% of Allowable Amount up to a $60 maximum 100% of Allowable Amount after $10 Copayment Amount

90% of Allowable Amount after Calendar Year Deductible 

Skilled Nursing Facility

60 days combined Calendar Year maximum



Home Health Care

60 visits combined Calendar Year maximum



Hospice Care 16

Unlimited

School Medical Plan Plan Provisions

In-Network Benefits

Out-of-Network Benefits

Mental Health Care, Serious Mental Illness, and Treatment of Chemical Dependency (Certain Services will require Preauthorization) Inpatient Services 

Hospital Services (facility)

80% of Allowable Amount after Calendar Year Deductible



Behavioral Health Practitioner Services

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $35 Copayment Amount 80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

Outpatient Services 

Behavioral Health Practitioner Expenses (office setting)



Other Outpatient Services

Emergency Care Accidental Injury & Emergency Care (including Accidental Injury & Emergency Care for Behavioral Health Services) 

Facility Charges



Lab & X- Ray - without emergency room or treatment room



Physician Charges

80% of Allowable Amount after $125 outpatient Hospital emergency room Copayment Amount (waived if admitted) 100% of Allowable Amount 80% of Allowable Amount after Calendar Year Deductible

Non-Emergency Care (including Non-Emergency Care for Behavioral Health Services)



Facility Charges



Physician Charges

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after $125 outpatient Hospital emergency room Copayment Amount (waived if admitted) and after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $50 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

80% of Allowable Amount after $125 outpatient Hospital emergency room Copayment Amount (waived if admitted)

Urgent Care Services Urgent Care Center visit - including Lab & X- Ray services (excluding Certain Diagnostic Procedures) Ambulance Services Retail Health Clinic

70% of Allowable Amount after Calendar Year Deductible 100% of Allowable Amount after $35 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

Preventative Care Services 





Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”) for infants, children, and adolescents

17

School Medical Plan Plan Provisions Preventive Care Services (Cont'd)  With respect to women, such additional preventive care and screenings, not described in the first bullet above, as provided for in comprehensive guidelines supported by the HRSA  Routine physical examinations, well baby care, immunizations, and routine Lab  Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures (Independent Lab & X- Ray Provider)  Colonoscopy, Physician and facility charges  Healthy diet counseling and obesity screening/ counseling 

Childhood immunizations

In-Network Benefits

Out-of-Network Benefits

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

100% of Allowable Amount

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

Other Routine Services 

Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures

 

Annual Hearing Examination Annual Vision Examination

Speech and Hearing Services 

Office visit

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible



All other services

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible

1 per ear per 36- month period for hearing aids Chiropractic Services (35 visits maximum per Calendar Year) 

Office visit



All other services



All other Outpatient Services



Airrosti Provider

100% of Allowable Amount after $35/$40 Copayment Amount 60% of Allowable Amount after Calendar Year Deductible 80% of Allowable Amount after Calendar Year Deductible 35 visits combined per Calendar Year maximum for above 80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible Does Not Apply

35 visits maximum per Calendar Year Physical Medicine Services (35 visits maximum per Calendar Year) 

Office visit/Office services

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible



All other outpatient services

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible

18

School Medical Pharmacy Benefits Plan Provisions

Participating Pharmacy

Non-Participating Pharmacy

Retail Pharmacy 90 day supply with 1 Copayment Amount per 30-day supply at a Participating Pharmacy $0 Copayment Amount

80% of Allowable Amount minus Copayment Amount

Preferred Brand Name Drugs

$35 Copayment Amount*

80% of Allowable Amount minus Copayment Amount

Non- Preferred Brand Name Drugs

$50 Copayment Amount*

80% of Allowable Amount minus Copayment Amount



Generic Drugs

 

Specialty Pharmacy Program Specialty Pharmacy Provider Specialty Drugs- limited to a 30-day supply at a $100 Copayment Amount* Specialty Pharmacy Provider Specialty Drugs Mail-Order Program One Copayment Amount per 90 day supply, up to a 90-day supply only 

Generic Drugs



Preferred Brand Name Drugs

$70 Copayment Amount*



Non- Preferred Brand Name Drugs

$100 Copayment Amount*

Not Covered

$0 Copayment Amount Not Covered

Select Participating Pharmacy 100% of Allowable Amount Select Vaccinations Obtained through Participating 80% of Allowable Amount minus Any other Participating Pharmacy 80% Pharmacies** Copayment Amount of Allowable Amount minus Copayment Amount Prior Authorization Provision Applies Step Therapy Provision Applies Limitations on Quantities Dispensed Applies Diabetes Supplies are available under the Pharmacy Benefits portion of your Plan. All provisions of this portion of the Plan Prescribed and over- the- counter will be paid under the Generic Copayment level, prescription would be needed to apply the generic Copayment Amount at the time of purchase.

Tobacco cessation drugs (including both prescription and over- the- counter drugs) prescribed by a Health Care Practitioner are covered at no cost share and will not be subject to Deductibles, Copayment Amounts and Co-Share Amounts for two 90- day treatment regimens per benefit period as required by the United States Preventive Services Task Force as referenced in the Preventive Care section of the PHARMACY BENEFITS portion of the Plan.

Contraceptive drugs and devices obtained from a Participating Pharmacy that are identified on the BCBSTX website under Contraceptive - Pharmacy information (referenced in the medical portion of the Plan as part of Benefits for Preventive Care Services) will not be subject to Deductibles, Copayment Amounts, and Co-Share Amounts.

Additional contraceptive drugs and contraceptive devices are covered under the Pharmacy portion of the Plan and are subject to the applicable Copayment Amounts, Co- Share Amounts, and any pricing differences. * If you receive a Preferred Brand Name Drug or a Non- Preferred Brand Name Drug when a Generic Drug is available, you may incur additional costs. Refer to the Pharmacy Benefits portion of this Benefit Booklet for details. ** Select Participating Pharmacies that have contracted with BCBSTX to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Vaccinations at all other pharmacies (participating and non- participating) will be payable at the non- participating benefit level. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. A Select Participating Pharmacy is a Pharmacy that has specifically contracted with BCBSTX to administer vaccinations to Participants.

Not all Participating Pharmacies are Select Participating Pharmacies.

NOTE: In the How Member Payment is Determined subsection of the PHARMACY BENEFITS section, an explanation of how the prescription drug products are separated into tiers is shown.

Dependent Eligibility Dependent Child Age Limit to age 26.

Dependent children are not eligible for Maternity Care Preexisting Conditions Preexisting conditions are covered immediately.

19

State Medical Plan Plan Provisions Deductibles  Per- admission Deductible 

Calendar Year Deductible Three- month Deductible carryover applies Applies to all Eligible Expenses Co-Share Stop-Loss Amounts (Includes Calendar Year Deductible and Copayment Amounts)

In-Network Benefits

Out-of-Network Benefits

None

$200 per- admission Deductible

$500– per individual

$1,500 – per individual

$1,500 – per family

$3,000 – per family

$4,000 – per individual

$6,000 – per individual

$8,000 – per family

$15,000 – per family

Copayment Amounts Required $25 Physician office visit  Physician office visit/consultation for Primary Care Providers $35 Physician office visit  Physician office visit/consultation for Specialty Care Providers  Outpatient Hospital Emergency Room/Treatment $100 outpatient Hospital Emergency Room/Treatment Room visit Room visit $45 Urgent Care Center visit  Urgent Care Center visit 

Retail Health Clinic

Does Not Apply Does Not Apply $100 outpatient Hospital Emergency Room/Treatment Room visit Does Not Apply

$25 Retail Health Clinic visit

Does Not Apply

85% of Allowable Amount after Calendar Year Deductible No penalty for failure to Preauthorize services

65% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible $250 penalty for failure to Preauthorize services

100% of Allowable Amount after $25/$35 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $25/$35 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible

85% of Allowable Amount after Calendar Year Deductible

65% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

65% of Allowable Amount after Calendar Year Deductible

Inpatient Hospital Expenses All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.

Medical-Surgical Expenses 

Office visit/consultation, (Primary Care Providers) including Lab and X- Rays

      

Radiation Therapy and Chemotherapy in the office setting Diabetic Management (training/nutritional) Inpatient visits Certain Diagnostic Procedures Home Infusion Therapy Physician surgical services in any setting Allergy Injections (without office visit)



Independent Lab and X-Ray



Services and supplies provided by Digi-Rad X-Ray Mobile  Services and supplies provided by Los Fresnos Medicine Clinic and Rio Hondo Medicine Clinic Extended Care Expenses

100% of Allowable Amount up to a $60 maximum 100% of Allowable Amount after $10 Copayment Amount

90% of Allowable Amount after Calendar Year Deductible 

Skilled Nursing Facility

60 days combined Calendar Year maximum



Home Health Care

60 visits combined Calendar Year maximum



Hospice Care 20

Unlimited

State Medical Plan Plan Provisions

In-Network Benefits

Out-of-Network Benefits

Mental Health Care, Serious Mental Illness, and Treatment of Chemical Dependency (Certain Services will require Preauthorization) Inpatient Services 

Hospital Services (facility)

85% of Allowable Amount after Calendar Year Deductible



Behavioral Health Practitioner Services

85% of Allowable Amount after Calendar Year Deductible

65% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible 65% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $25 Copayment Amount 85% of Allowable Amount after Calendar Year Deductible

65% of Allowable Amount after Calendar Year Deductible 65% of Allowable Amount after Calendar Year Deductible

Outpatient Services 

Behavioral Health Practitioner Expenses (office setting)



Other Outpatient Services

Emergency Care Accidental Injury & Emergency Care (including Accidental Injury & Emergency Care for Behavioral Health Services) 

Facility Charges



Lab & X- Ray - without emergency room or treatment room



Physician Charges

85% of Allowable Amount after $100 outpatient Hospital emergency room Copayment Amount (waived if admitted) 100% of Allowable Amount 85% of Allowable Amount after Calendar Year Deductible

Non-Emergency Care (including Non-Emergency Care for Behavioral Health Services)



Facility Charges



Physician Charges

85% of Allowable Amount after Calendar Year Deductible

65% of Allowable Amount after $100 outpatient Hospital emergency room Copayment Amount (waived if admitted) and after Calendar Year Deductible 65% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $45 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible

85% of Allowable Amount after $100 outpatient Hospital emergency room Copayment Amount (waived if admitted)

Urgent Care Services Urgent Care Center visit - including Lab & X- Ray services (excluding Certain Diagnostic Procedures) Ambulance Services Retail Health Clinic

85% of Allowable Amount after Calendar Year Deductible 100% of Allowable Amount after $25 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

65% of Allowable Amount after Calendar Year Deductible

Preventative Care Services 





Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”) for infants, children, and adolescents

21

State Medical Plan Plan Provisions Preventive Care Services (Cont'd)  With respect to women, such additional preventive care and screenings, not described in the first bullet above, as provided for in comprehensive guidelines supported by the HRSA  Routine physical examinations, well baby care, immunizations, and routine Lab  Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures (Independent Lab & X- Ray Provider)  Colonoscopy, Physician and facility charges  Healthy diet counseling and obesity screening/ counseling 

Childhood immunizations

In-Network Benefits

Out-of-Network Benefits

100% of Allowable Amount

65% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

100% of Allowable Amount

100% of Allowable Amount

65% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $25/$35 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible

Other Routine Services 

Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures

 

Annual Hearing Examination Annual Vision Examination

Speech and Hearing Services 

Office visit

100% of Allowable Amount after $25/$35 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible



All other services

85% of Allowable Amount after Calendar Year Deductible

65% of Allowable Amount after Calendar Year Deductible

1 per ear per 36- month period for hearing aids Chiropractic Services (35 visits maximum per Calendar Year) 

Office visit

100% of Allowable Amount after $35/$40 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible

65% of Allowable Amount after 65% of Allowable Amount after Calendar Year Deductible Calendar Year Deductible 35 visits combined per Calendar Year maximum for above 100% of Allowable Amount after Does Not Apply $25 Copayment Amount  Airrosti Provider 35 visits maximum per Calendar Year Physical Medicine Services (35 visits maximum per Calendar Year) 

All other services



Office visit/Office services

100% of Allowable Amount after $25/$35 Copayment Amount

65% of Allowable Amount after Calendar Year Deductible



All other outpatient services

85% of Allowable Amount after Calendar Year Deductible

65% of Allowable Amount after Calendar Year Deductible

22

State Medical Pharmacy Benefits Plan Provisions

Participating Pharmacy

Non-Participating Pharmacy

Retail Pharmacy 90 day supply with 1 Copayment Amount per 30-day supply at a Participating Pharmacy $0 Copayment Amount

80% of Allowable Amount minus Copayment Amount

Preferred Brand Name Drugs

$30 Copayment Amount*

80% of Allowable Amount minus Copayment Amount

Non- Preferred Brand Name Drugs

$45 Copayment Amount*

80% of Allowable Amount minus Copayment Amount



Generic Drugs

 

Specialty Pharmacy Program Specialty Pharmacy Provider Specialty Drugs- limited to a 30-day supply at a $100 Copayment Amount* Specialty Pharmacy Provider Specialty Drugs Mail-Order Program One Copayment Amount per 90 day supply, up to a 90-day supply only 

Generic Drugs



Preferred Brand Name Drugs

$70 Copayment Amount*



Non- Preferred Brand Name Drugs

$90 Copayment Amount*

Not Covered

$0 Copayment Amount Not Covered

Select Participating Pharmacy 100% of Allowable Amount Select Vaccinations Obtained through Participating 80% of Allowable Amount minus Any other Participating Pharmacy 80% Pharmacies** Copayment Amount of Allowable Amount minus Copayment Amount Prior Authorization Provision Applies Step Therapy Provision Applies Limitations on Quantities Dispensed Applies Diabetes Supplies are available under the Pharmacy Benefits portion of your Plan. All provisions of this portion of the Plan Prescribed and over- the- counter will be paid under the Generic Copayment level, prescription would be needed to apply the generic Copayment Amount at the time of purchase.

Tobacco cessation drugs (including both prescription and over- the- counter drugs) prescribed by a Health Care Practitioner are covered at no cost share and will not be subject to Deductibles, Copayment Amounts and Co-Share Amounts for two 90- day treatment regimens per benefit period as required by the United States Preventive Services Task Force as referenced in the Preventive Care section of the PHARMACY BENEFITS portion of the Plan.

Contraceptive drugs and devices obtained from a Participating Pharmacy that are identified on the BCBSTX website under Contraceptive - Pharmacy information (referenced in the medical portion of the Plan as part of Benefits for Preventive Care Services) will not be subject to Deductibles, Copayment Amounts, and Co-Share Amounts.

Additional contraceptive drugs and contraceptive devices are covered under the Pharmacy portion of the Plan and are subject to the applicable Copayment Amounts, Co- Share Amounts, and any pricing differences. * If you receive a Preferred Brand Name Drug or a Non- Preferred Brand Name Drug when a Generic Drug is available, you may incur additional costs. Refer to the Pharmacy Benefits portion of this Benefit Booklet for details. ** Select Participating Pharmacies that have contracted with BCBSTX to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Vaccinations at all other pharmacies (participating and non- participating) will be payable at the non- participating benefit level. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. A Select Participating Pharmacy is a Pharmacy that has specifically contracted with BCBSTX to administer vaccinations to Participants.

Not all Participating Pharmacies are Select Participating Pharmacies.

NOTE: In the How Member Payment is Determined subsection of the PHARMACY BENEFITS section, an explanation of how the prescription drug products are separated into tiers is shown.

Dependent Eligibility Dependent Child Age Limit to age 26.

Dependent children are not eligible for Maternity Care Preexisting Conditions Preexisting conditions are covered immediately.

23

BCBSTX

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 24 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Dental Plan PLAN OVERALL PAYMENT PROVISIONS

DENTAL BENEFITS

Deductibles Calendar Year Deductible Three month Deductible carryover applies

$50 – per individual $150 – per family

Maximum Calendar Year Benefits per Participant for Categories I, II, III, IV, V, VI, VII, VIII, IX, X

$ 1,250

Does not apply to Orthodontic I.

Diagnostic & Preventive Care Services

90% of Allowable Amount

II. Miscellaneous Services

80% of Allowable Amount after Calendar Year Deductible

III. Restorative Services

80% of Allowable Amount after Calendar Year Deductible

IV. General Services

80% of Allowable Amount after Calendar Year Deductible

V. Endodontic Services

80% of Allowable Amount after Calendar Year Deductible

VI. Periodontal Services

80% of Allowable Amount after Calendar Year Deductible

VII. Oral Surgery Services

80% of Allowable Amount after Calendar Year Deductible

VIII. Crowns, Inlays/Onlays Services

50% of Allowable Amount after Calendar Year Deductible

IX. Prosthodontic Services

50% of Allowable Amount after Calendar Year Deductible

OPTIONAL COVERAGE X. Implant Services

50% of Allowable Amount after Calendar Year Deductible

XI. Orthodontic Services All Participants $1,250 maximum lifetime benefit

50% of Allowable Amount

Predetermination Amount

$300

Dependent Child Age Limit

Age 26 MONTHLY PREMIUMS 12 Pay

18 Pay

24 Pay

Employee Only

$22.00

$14.67

$11.00

Employee + Child

$34.00

$22.67

$17.00

Employee + Children

$49.00

$32.67

$24.50

Employee + Spouse

$47.00

$31.33

$23.50

Employee + Family

$62.00

$41.33

$31.00

25

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 26 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Vision CO-PAYS

VISION PLAN BENEFITS

Exam

$10

Materials

$10

Benefits Exam

In-Network Covered in full

Out-of-Network Up to $35 retail

Frames

$130 retail allowance

Up to $70 retail

Single Vision

Covered in full

Up to $25 retail

Bifocal

Covered in full

Up to $40 retail

Trifocal

Covered in full

Up to $45 retail

See description1

Up to $45 retail

Lenticular

Covered in full

Up to $80 retail

Contact Lenses2

$150 retail allowance

Up to $80 retail

Emp. only

Covered in full

Up to $150 retail

Emp. + 1 dependent $14.15

Lenses (standard) per pair

Progressive

Medically Necessary Contact Lenses

SERVICES/FREQUENCY Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

MONTHLY PREMIUMS

Emp. + family

$8.30 $20.79

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 2 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

27

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 28 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Long Term Disability Long Term Disability (LTD) Insurance Coverage Long-Term Disability Insurance pays you a portion of your earnings if you cannot work because of a disabling illness or injury. You have the opportunity to purchase Long-Term Disability Insurance through What is Long-Term your employer.

Disability Insurance?

This highlight sheet is an overview of your Long-Term Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

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

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

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

You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between How much coverage $200 and $8,000 that cannot exceed 66 2/3% of your current monthly earnings. Your plan includes a would I have? minimum benefit, greater of 10% of your elected benefit or $100.

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

You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours.

What is does “Actively If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are at Work” mean? able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.

The table below applies to disabilities resulting from sickness or injury: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

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

Mental Illness, Alcoholism and Substance Abuse

Pre-existing Conditions:

 

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

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

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

Your 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 6 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: 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.

Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:

Your benefit payments will not be reduced by certain kinds of other income, such as:





 

Social Security Disability Insurance or alternative plan (please see next section for exceptions) Workers' Compensation Other employer-based Insurance coverage you may have

  

Unemployment benefits Settlements or judgments for income loss Retirement benefits that your employer fully or partially pays for (such as a pension plan.)



Retirement benefits if you were already receiving them before you became disabled The portion of your Long Term Disability payment that you place in an IRS-approved account to fund your future retirement.

   

Your personal savings, investments, IRAs or Keoghs Profit-sharing Most personal disability policies Social Security increases 29

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Breast Cancer is the most commonly diagnosed cancer in women.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 30 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Los Fresnos CISD THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

SUMMARY OF BENEFITS

Plan 1

Cancer Treatment Policy Benefits

Level 1

Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period

$10,000

Hormone Therapy - Maximum of 12 treatments per calendar year

$50 per treatment

Experimental Treatment

paid in same manner and under the same maximums as any other benefit Level 2

Surgical Rider Benefits

$30 unit dollar amount Max $3,000 per operation

Surgical Anesthesia

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime

$6,000

Stem Cell Transplant - Maximum per lifetime

$600

Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime

$1,000 / $100

Internal Cancer First Occurrence Rider Benefits

Level 1

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$2,500

Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime

$3,750

Hospital Intensive Care Unit Rider Benefits Intensive Care Unit

$600 per day

Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

$300 per day

TOTAL MONTHLY PREMIUMS BY PLAN** Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18 +

$13.42

$28.36

$17.60

$32.50

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

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

Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.

Cancer Treatment Benefits Eligibility

You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, incontestability and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Waiting Period

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium.

If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

31

APSB-22339(TX)-0518 FBS Los Fresnos CISD

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Termination of Certificate

Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.

Termination of Coverage

Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death.

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

Surgical Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a preexisting condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Termination of Surgical Benefit Rider The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.

Internal Cancer First Occurrence Benefits Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.

Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

32

APSB-22339(TX)-0518 FBS Los Fresnos CISD

Hospital Intensive Care Unit Benefits Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date.

We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Optionally Renewable This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

Portability (Voluntary Plans Only) When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.

The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision.

No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request.

Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Los Fresnos CISD THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

SUMMARY OF BENEFITS

Plan 2

Cancer Treatment Policy Benefits

Level 4

Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period

$20,000

Hormone Therapy - Maximum of 12 treatments per calendar year

$50 per treatment

Experimental Treatment

paid in same manner and under the same maximums as any other benefit Level 2

Surgical Rider Benefits

$30 unit dollar amount Max $3,000 per operation

Surgical Anesthesia

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime

$6,000

Stem Cell Transplant - Maximum per lifetime

$600

Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime

$1,000 / $100

Internal Cancer First Occurrence Rider Benefits

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime

$7,500

Hospital Intensive Care Unit Rider Benefits Intensive Care Unit

$600 per day

Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

$300 per day

TOTAL MONTHLY PREMIUMS BY PLAN** Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18 +

$19.68

$41.18

$25.04

$46.56

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

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

Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.

Cancer Treatment Benefits Eligibility

You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, incontestability and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Waiting Period

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium.

If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

33

APSB-22339(TX)-0518 FBS Los Fresnos CISD

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Termination of Certificate

Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.

Termination of Coverage

Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death.

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

Surgical Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a preexisting condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Termination of Surgical Benefit Rider The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.

Internal Cancer First Occurrence Benefits Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.

Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

34

APSB-22339(TX)-0518 FBS Los Fresnos CISD

Hospital Intensive Care Unit Benefits Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date.

We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Optionally Renewable This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

Portability (Voluntary Plans Only) When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.

The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision.

No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request.

Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Specified Disease Cancer Indemnity Insurance | (09/17) | FBS | Los Fresnos CISD

APSB-22339(TX)-0518 FBS Los Fresnos CISD

35

VOYA

Critical Illness

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 36 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Critical Illness What is Critical Illness Insurance?

Critical Illness Insurance pays a lump-sum benefit if you are diagnosed after your effective date of coverage with a covered illness or condition listed below. Please review certificates of coverage for any limitations that may apply. Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

For what critical illnesses and conditions are benefits available?         

       

Base Module Heart attack*  Coronary artery bypass (25%) Cancer  Carcinoma in situ (25%) Stroke Major organ transplant** Major Organ Module Type 1 Diabetes  Severe burns Transient ischemic  Transcatheter heart valve attacks (TIA) (10% ) replacement or repair (10%) Abdominal aortic  Coronary angioplasty (10% aneurysm (10%  Implantable/internal Thoracic aortic aneurysm cardioverter defibrillator (ICD) (10% placement (10%) Open heart surgery for  Pacemaker placement (10% valve replacement or repair (10%) Enhanced Cancer Module Benign brain tumor  Bone marrow transplant (25%) Skin cancer (10%)  Stem cell transplant (25%) Additional Child Diseases Module*** Niemann-Pick disease Cerebral palsy Congenital birth defects Pompe disease Sickle cell anemia Cystic fibrosis Type 1 diabetes Down syndrome Type IV glycogen storage disease Gaucher disease, type II Zellweger syndrome or III Infantile Tay-Sachs

* A sudden cardiac arrest is not in itself considered a heart attack. ** Major organ transplant means the irreversible failure of your heart, lung, pancreas, entire kidney or liver, or any combination thereof, determined by a physician specialized in care of the involved organ. *** This module applies to your insured children only, and is in addition to the other modules available.

What additional benefits does my Critical Illness Insurance include?

The benefits listed below are also included with your Critical Illness coverage.  Wellness Benefit: This provides an annual benefit payment if you complete a health screening test.  Your annual benefit amount is $50 for completing a health screening test.  Your spouse’s annual benefit amount is $50 for completing a health screening test.  The annual benefit amount for each child is $25 with an annual maximum of $100 for all children.

Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

$5,000 $2.15 $2.30 $2.50 $3.10 $4.25 $6.25 $9.40 $13.95 $18.20 $24.35 $36.50

Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

$5,000 $3.55 $3.80 $4.20 $5.35 $7.65 $11.55 $17.80 $26.80 $35.20 $47.30 $71.25

Employee Coverage Monthly Rates Non-Tobacco User $10,000 $15,000 $20,000 $4.30 $6.45 $8.60 $4.60 $6.90 $9.20 $5.00 $7.50 $10.00 $6.20 $9.30 $12.40 $8.50 $12.75 $17.00 $12.50 $18.75 $25.00 $18.80 $28.20 $37.60 $27.90 $41.85 $55.80 $36.40 $54.60 $72.80 $48.70 $73.05 $97.40 $73.00 $109.50 $146.00 Tobacco User $10,000 $15,000 $20,000 $7.10 $10.65 $14.20 $7.60 $11.40 $15.20 $8.40 $12.60 $16.80 $10.70 $16.05 $21.40 $15.30 $22.95 $30.60 $23.10 $34.65 $46.20 $35.60 $53.40 $71.20 $53.60 $80.40 $107.20 $70.40 $105.60 $140.80 $94.60 $141.90 $189.20 $142.50 $213.75 $285.00

$25,000 $10.75 $11.50 $12.50 $15.50 $21.25 $31.25 $47.00 $69.75 $91.00 $121.75 $182.50

$30,000 $12.90 $13.80 $15.00 $18.60 $25.50 $37.50 $56.40 $83.70 $109.20 $146.10 $219.00

$25,000 $17.75 $19.00 $21.00 $26.75 $38.25 $57.75 $89.00 $134.00 $176.00 $236.50 $356.25

$30,000 $21.30 $22.80 $25.20 $32.10 $45.90 $69.30 $106.80 $160.80 $211.20 $283.80 $427.50

Spouse Coverage* Monthly Rates Includes Wellness Benefit Rider Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Tobacco User Age $5,000 $10,000 $15,000 $7.10 $6.45 Under 25 $3.55 25-29 $3.80 $7.60 $6.90 30-34 $4.20 $8.40 $7.50 35-39 $5.35 $10.70 $9.30 40-44 $7.65 $15.30 $12.75 45-49 $11.55 $23.10 $18.75 50-54 $17.80 $35.60 $28.20 55-59 $26.80 $53.60 $41.85 60-64 $35.20 $70.40 $54.60 65-69 $47.30 $94.60 $73.05 70+ $71.25 $142.50 $109.50 Children Coverage Monthly Rates Includes Wellness Benefit Rider Coverage Amount Rate $1,000 $0.57 $2,500 $1.43 $5,000 $2.85 $10,000 $5.70

Non-Tobacco User $5,000 $10,000 $2.15 $4.30 $2.30 $4.60 $2.50 $5.00 $3.10 $6.20 $4.25 $8.50 $6.25 $12.50 $9.40 $18.80 $13.95 $27.90 $18.20 $36.40 $24.35 $48.70 $36.50 $73.00

$15,000 $10.65 $11.40 $12.60 $16.05 $22.95 $34.65 $53.40 $80.40 $105.60 $141.90 $213.75

Benefit Reductions Benefits may reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70th birthday, however, premiums do not reduce as a result of this benefit change. *See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.

37

THE HARTFORD 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 38 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Accident your major medical plan to day-to-day costs of living such as the mortgage or your utility bills.

With Accident insurance, you’ll receive payment(s) associated COVERAGE INFORMATION with a covered injury and related services. You can use the payment in any way you choose – from expenses not covered by This insurance provides benefits when injuries, medical treatment and/or services occur as the result of a covered

What accident benefits are available?

PLAN INFORMATION Coverage Type BENEFITS EMERGENCY, HOSPITAL & TREATMENT CARE Accident Follow-Up Acupuncture/Chiropractic Care/PT Ambulance – Air Ambulance – Ground Blood/Plasma/Platelets Child Care Daily Hospital Confinement Daily ICU Confinement Diagnostic Exam Emergency Dental Emergency Room Hospital Admission Initial Physician Office Visit Lodging Medical Appliance Rehabilitation Facility Transportation Urgent Care X-ray SPECIFIED INJURY & SURGERY Abdominal/Thoracic Surgery Arthroscopic Surgery Burn Burn – Skin Graft Concussion Dislocation Eye Injury Fracture Hernia Repair Joint Replacement Knee Cartilage Laceration Ruptured Disc Tendon/Ligament/Rotator Cuff FEATURES Ability Assist® EAP2 – 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM2 – Administrative & clinical support following serious illness or injury

OPTION 1 Off-job only OPTION 1 Up to 3 visits per accident Up to 10 visits each per accident Once per accident Once per accident Once per accident Up to 30 days per accident while insured is confined Up to 365 days per lifetime Up to 30 days per accident Once per accident Once per accident Once per accident Once per accident Once per accident Up to 30 nights per lifetime Once per accident Up to 15 days per lifetime Up to 3 trips per accident Once per accident Once per accident Once per accident Once per accident Once per accident Once per accident for third degree burn(s) Up to 3 per year Once per joint per lifetime Once per accident Once per bone per accident Once per accident Once per accident Once per accident Once per accident Once per accident Up to 2 per accident Ability Assist® EAP2 – 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM2 – Administrative & clinical support following serious illness or injury

$100 $50 $1,200 $400 $300 $30 $300 $600 $300 Up to $450 $200 $1,500 $100 $150 $150 $150 $500 $100 $75 OPTION 1 $2,000 $400 Up to $15,000 25% of burn benefit $200 Up to $8,000 Up to $600 Up to $9,000 $200 $3,000 Up to $1,000 Up to $600 $1,000 Up to $1,500 OPTION 1 Included Included

COVERAGE TIER Employee Only

$11.78 ($0.39 per day)

Employee & Spouse

$18.56 ($0.61 per day)

Employee & Child(ren)

$20.12 ($0.66 per day)

Employee & Family

$31.50 ($1.04 per day) 39

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 40 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Life and AD&D Group Term Life Including matching AD&D Coverage   

Los Fresnos CISD provides all eligible employees with $10,000 Basic Life with AD&D. Accelerated life benefit Addi onal AD&D Benefits: Seat Belt, Air Bag, Repatria on, Child Higher Educa on, Child Care, Paralysis/Loss of Use, Severe Burns

Eligible Employees This benefit is available for employees who are ac vely at work on the effec ve date and working a minimum of 15 hours per week.

Accidental Death & Dismemberment (AD&D)

Voluntary Term Life Benefits Flexible Op ons Employee: $10,000 to $500,000, in $10,000 increments, not to exceed 7 mes your annual salary Spouse under age 70: $5,000 to $250,000, in $5,000 increments, not to exceed 100% of the employee’s amount

Guaranteed Issue Employee: Spouse: Child:

$250,000 $30,000 $10,000

Dependent Life Coverage Op onal dependent life coverage is available to eligible employees. You must select employee coverage in order to cover your spouse and/or child(ren).

Accelerated Life Benefit

Addi onal life insurance benefits may be payable in the event of If diagnosed with a terminal illness and have less than 12 an accident which results in death or dismemberment as defined months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose. in the contract. Addi onal AD&D benefits include seat belt, air bag, repatria on, child higher educa on, child care, paralysis/ Guaranteed Increase in Benefit loss of use, severe burns, disappearance, and exposure.

You may be eligible to increase your coverage annually un l you reach your maximum amount without providing evidence of Timely Enrollment insurability.

Enrolling mely means you have enrolled during the ini al enrollment period when benefits were first offered by Reduc ons OneAmerica, or as a newly hired employee within 31 days Upon reaching certain ages, your original benefit amount will following comple on of any applicable wai ng period. reduce to a percentage as shown in the following schedule. The amounts of Dependent Life Insurance and Dependent AD&D Accelerated Life Benefit Principal Sum will reduce according to the Employee's reduc on If diagnosed with a terminal illness and have less than 12 schedule. months to live, you may apply to receive 25%, 50% or 75% of Age: 70 your life insurance benefit to use for whatever you choose.

Reduces To: 50%

41

Life and AD&D Voluntary Term Life Coverage Monthly Payroll Deduction Illustration Age Category

Monthly Premium Rates Per $10,000 of Coverage

0-24 25-29 30-34 35-39 40-44 45-49 50-54

Employee $0.30 $0.30 $0.40 $0.70 $0.80 $1.30 $2.10

Spouse $0.15 $0.15 $0.20 $0.35 $0.40 $0.65 $1.05

55-59

$3.70

$1.85

60-64

$4.80

$2.40

65-69

$9.10

$4.55

70-74

$14.70

$7.35

75+

$14.70

$7.35

Child Life Benefit 6 months to age 26 Live birth to 6 months Monthly Deduction

$10,000 $1,000 $1.00

Voluntary AD&D Benefits Flexible AD&D Options:

Employee: Up to $500,000, in $10,000 increments Spouse: 50% of the employee AD&D benefit Child: $10,000

AD&D Guaranteed Issue:

Employee: $500,000 Spouse: $250,000 Child: $10,000

Accidental Death and Dismemberment (AD&D):

If AD&D is selected, additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract.

Dependent AD&D Coverage:

Optional dependent AD&D coverage is available to eligible employees. You must select employee coverage in order to cover your spouse and/or child(ren). If employee AD&D is declined, no dependent AD&D will be included.

Reductions:

Upon reaching certain ages, your original benefit amount will reduce to the percentage shown in the following schedule. The amounts of dependent AD&D principal sum will reduce according to the employee's reduction schedule.

Age:

70

Reduces To:

50%

Payroll Deduction Illustration: Monthly AD&D Options Per $10,000 Benefit Coverage

EE Only

EE & SP

EE & CH

$0.20

$0.30

$0.70

Family

Employee premiums are based on your age as of 01/01. Spouse premiums are based on your spouse's age as of 01/01. Child premiums are for all eligible children combined.

42

ComPsych GuidanceResources® Program “Employee Assistance Program" this benefit is provided by LFCISD and no additional charge to the employee.

Confiden al Counseling

Work‐Life Solu ons

This no‐cost counseling service helps you address stress, rela onship and other personal issues you and your family may face. It is staffed by GuidanceConsultantsSM—highly trained master’s and doctoral level clinicians who will listen to your concerns and quickly refer you to in‐person counseling (up to 3 sessions per year) and other resources for: › Stress, anxiety and depression › Job pressures › Rela onship/marital conflicts › Grief and loss › Problems with children › Substance abuse

Our Work‐Life specialists will do the research for you, providing qualified referrals and customized resources for: › Child and elder care › College planning › Moving and reloca on › Pet care › Home repair › Making major purchases

Financial Informa on and Resources Speak by phone with our Cer fied Public Accountants and Cer fied Financial Planners on a wide range of financial issues including: › Ge ng out of debt › Re rement planning › Credit card or loan problems › Estate planning › Tax ques ons › Saving for college

Legal Support and Resources Talk to our a orneys by phone. If you require representa on, we’ll refer you to a qualified a orney in your area for a free 30‐ minute consulta on with a 25% reduc on in customary legal fees therea er. Call about: › Divorce and family law › Real estate transac ons › Debt and bankruptcy › Civil and criminal ac ons › Landlord/tenant issues › Contracts

GuidanceResources® Online GuidanceResources Online is your one stop for expert informa on on the issues that ma er most to you… rela onships, work, school, children, wellness, legal, financial, free me and more. › Timely ar cles, HelpSheetsSM, tutorials, streaming videos and self‐assessments › “Ask the Expert” personal responses to your ques ons › Child care, elder care, a orney and financial planner searches

Free Online Will Prepara on EstateGuidance® lets you quickly and easily write a will on your computer. Just go to www.guidanceresources.com and click on the EstateGuidance link. Follow the prompts to create and download your will at no cost. Online support and instruc ons for execu ng and filing your will are included. You can: › Name an executor to manage your estate › Choose a guardian for your children › Specify your wishes for your property › Provide funeral and burial instruc ons

Call 855.387.9727 OR GO TO www.guidanceresources.com Use Web ID: ONEAMERICA3

OneAmerica is the marke ng name for American United Life Insurance Company® (AUL). AUL markets ComPsych services. ComPsych Corpora on is not an affiliate of AUL and is not a OneAmerica company.

43

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.

FLIP TO‌ PG. 11 FOR FSA FACTS

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 44 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card.

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

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you need a replacement card please contact NBS directly at (800) 274-0503.

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

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

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

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

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

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

FSA Annual Contribution Max: $2,700

Dependent Care Annual Max: $5,000

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

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

Online claims FAQs

45

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/losfresnoscisd

46

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

How To Receive Your Dependent Care Reimbursement Faster.

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

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

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

Get Your Money 1.

2.

3.

4.

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

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

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

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

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

Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year.

47

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 48 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

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.

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

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

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

What is Covered?  

Emergency Helicopter Transport Emergency Ground Ambulance Transport

How Much Does It Cost?

MASA Emergent rates are $9 a month, per employee/family coverage.

Emergent Card Example:

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

49

NOTES

50

NOTES

51

WWW.MYBENEFITSHUB.COM/ LOSFRESNOSCISD 52