2022-23 Jacksonville ISD Benefit Guide

2022 - 2023 Plan Year

JACKSONVILLE ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2022 - 8/31/2023 WWW.MYBENEFITSHUB.COM/JACKSONVILLEISD

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Table of Contents

How to Enroll Annual Benefit Enrollment 1. Annual Enrollment 2. Section 125 Cafeteria Plan Guidelines 3. Helpful Definitions 4. Eligibility Requirements 5. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) Medical Health Savings Account (HSA) Dental Vision Disability Cancer Basic Life and AD&D Voluntary Life and AD&D Individual Life Flexible Spending Account (FSA) Hospital Indemnity

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4-5 6-11 6 7 8 9 10

12-17 18 19-20 21 22-23 24-25 26-27 28-29 30-31 32-33 34

FLIP TO...

PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

Benefit Contact Information BENEFIT ADMINISTRATORS

DENTAL

HOSPITAL INDEMNITY

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

CIGNA Group# 3338975 (800) 244-6224 www.mycigna.com

The Hartford Group# 11846982 (800) 523-2233 File a claim : (866) 278-2655

JACKSONVILLE ISD BENEFITS OFFICE VISION

LIFE AND AD&D

(903) 586-6511 www.jisd.org

Superior Vision Group# 320510 (800) 507-3800 www.superiorvision.com

Lincoln Financial Group (800) 423-2765 www.lfg.com

TRS ACTIVECARE MEDICAL

DISABILITY

FLEXIBLE SPENDING ACCOUNT (FSA)

BCBS 866-355-5999 www.bcbstx.com/trsactivecare

The Hartford Group# 873359 (800) 523-2233 File a claim : (866) 278-2655 www.thehartford.com

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

HEALTH SAVINGS ACCOUNTS (HSA)

CANCER

INDIVIDUAL LIFE

EECU (800) 333-9934 www.eecu.org

American Public Life (APL) Group# 11846936 (800) 256-8606 www.ampublic.com

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

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All Your Benefits One App Employee benefits made easy through the FBS Benefits App! Text “FBS JISD” to (800) 583-6908 and get access to everything you need to complete your

benefits enrollment: •

Benefit Resources

•

Online Enrollment

•

Interactive Tools

•

And more!

App Group #: FBSJISD

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Text

“FBS JISD”

to (800) 583-6908 OR SCAN

How to Log In 1

www.mybenefitshub.com/jacksonvilleisd

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CLICK LOGIN

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ENTER USERNAME & PASSWORD Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

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

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Annual Benefit Enrollment

SUMMARY PAGES

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

•

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

• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile.

Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.

•

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

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 30 days of benefit eligible employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions?

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

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Where can I find forms?

For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/ jacksonvilleisd. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the Jacksonville ISD benefit website: www.mybenefitshub.com/jacksonvilleisd. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

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

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

Annual Benefit Enrollment

SUMMARY PAGES

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

Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

CHANGES IN STATUS (CIS): Marital Status

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 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 A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).

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

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

Gain/Loss of Dependents' Eligibility Status

Judgment/Decree/ Order

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent 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 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

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SUMMARY PAGES

Helpful Definitions Actively-at-Work

In-Network

You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2022 please notify your benefits administrator.

Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.

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.

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 preexisting condition exclusion provisions do apply, as applicable by carrier.

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

Plan Year September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescription drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).

Annual Benefit Enrollment

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.

Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.

Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2022 benefits become effective on September 1, 2022, you must be actively-at-work on September 1, 2022 to be eligible for your new benefits.

PLAN

MAXIMUM AGE

Medical

To Age 26

Dental

To Age 26

Vision

To Age 26

Cancer

To Age 25

Individual Life

Issue to 24; Keep to 100

Voluntary Life and AD&D

To Age 26

Hospital Indemnity

To Age 26

Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents.

Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility.

FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance.

Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility.

Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.

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

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SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee and/or employer

Employee and/or employer

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Minimum Deductible

$1,400 single (2022) $2,800 family (2022)

N/A

Maximum Contribution

$3,650 single (2022) $7,300 family (2022)

$2,850 (2022)

Permissible Use Of Funds

Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

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

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

Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age Not permitted 65).

Description

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

No

Portable?

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

No

FLIP TO FOR HSA INFORMATION

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PG. 18

FLIP TO FOR FSA INFORMATION

PG. 32

Notes

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Medical Insurance

EMPLOYEE BENEFITS

TRS ABOUT MEDICAL Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

Monthly Premium

District Contribution

Employee Cost

TRS ActiveCare HD Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$423.00

$270.00

$153.00

$1,189.00

$270.00

$919.00

$759.00

$270.00

$489.00

$1,422.00

$270.00

$1,152.00

TRS ActiveCare 2 Employee Only

$1,013.00

$270.00

$743.00

Employee & Spouse

$2,402.00

$270.00

$2,132.00

Employee & Child(ren)

$1,507.00

$270.00

$1,237.00

Employee & Family

$2,841.00

$270.00

$2,571.00

TRS ActiveCare Primary Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$408.00

$270.00

$138.00

$1,151.00

$270.00

$881.00

$734.00

$270.00

$464.00

$1,378.00

$270.00

$1,108.00

TRS ActiveCare Primary+ Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$513.00

$270.00

$243.00

$1,254.00

$270.00

$984.00

$825.00

$270.00

$555.00

$1,577.00

$270.00

$1,307.00

West Texas Blue Essentials HMO Employee Only Employee & Spouse Employee & Child(ren)

Employee & Family 12

$542.48

$270.00

$272.48

$1,362.70

$270.00

$1,092.70

$872.16

$270.00

$602.16

$1,568.42

$270.00

$1,298.42

Medical Insurance Carrier Name

EMPLOYEE BENEFITS

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Health Savings Account (HSA) EECU

EMPLOYEE BENEFITS

ABOUT HSA A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used.

Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP).

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

A Health Savings Account (HSA) is more than a way to help you and your family cover health care costs – it is also a tax-exempt tool to supplement your retirement savings and cover health expenses during retirement. An HSA can provide the funds to help pay current health care expenses as well as future health care costs.

You decide whether to use the money in your account to pay for qualified expenses or let it grow for future use. If you are 55 or older, you may make a yearly catch-up contribution of up to $1,000 to your HSA. If you turn 55 at any time during the plan year, you are eligible to make the catch-up contribution for the entire plan year.

A type of personal savings account, an HSA is always yours even if you change health plans or jobs. The money in your HSA (including interest and investment earnings) grows tax-free and spends tax-free if used to pay for qualified medical expenses.

There is no “use it or lose it” rule — you do not lose your money if you do not spend it in the calendar year — and there are no vesting requirements or forfeiture provisions. The account automatically rolls over year after year.

Opening an HSA

HSA Eligibility

If you meet the eligibility requirements, you may open an HSA administered by EECU. You will receive a debit card to manage your HSA account reimbursements. Keep in mind, available funds are limited to the balance in your HSA. To open an account, go to https://www.eecu.org/.

Important HSA Information •

Always ask your health care provider to file claims with your medical provider so network discounts can be applied. You can pay the provider with your HSA debit card based on the balance due after discount.

You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit.

You may open an HSA at the financial institution of your choice, but only accounts opened through EECU are eligible for automatic payroll deduction and company contributions.

You are eligible to open and contribute to an HSA if you are: • Enrolled in an HSA-eligible HDHP • Not covered by another plan that is not a qualified HDHP, • such as your spouse’s health plan • Not enrolled in a Health Care Flexible Spending Account • Not eligible to be claimed as a dependent on someone else’s • tax return • Not enrolled in Medicare or TRICARE • Not receiving Veterans Administration benefits You can use the money in your HSA to pay for qualified medical How to Use your HSA expenses now or in the future. You can also use HSA funds to pay • Online/Mobile: Sign-in for 24/7 account access to check your health care expenses for your dependents, even if they are not balance, pay bills and more. covered by the HDHP. • Call/Text: (817) 882-0800. EECU’s dedicated member service representatives are available to assist you with any Maximum Contributions questions. Their hours of operation are Monday through Your HSA contributions may not exceed the annual maximum Friday from 8:00 a.m. to 7:00 p.m. CT, Saturday 9:00 a.m. – amount established by the Internal Revenue Service. The annual 1:00 p.m. CT and closed on Sunday. contribution maximum for 2022 is based on the coverage option • Lost/Stolen Debit Card: Call the 24/7 debit card hotline at you elect: (800) 333-9934 • Individual – $3,650 • Stop by: a local EECU financial center for in-person • Family (filing jointly) – $7,300 assistance: www.eecu.org/locations.

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Dental Insurance

EMPLOYEE BENEFITS

Cigna ABOUT DENTAL Dental insurance is a coverage that helps defray the costs of dental care.

It insures against the expense of routine care, dental treatment and disease.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

HIGH PLAN Network Options

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Reimbursement Levels

Based on Contracted Fees

Maximum Reimbursable Charge

$1,000

$1,000

$50 $150

$50 $150

Calendar Year Benefits Maximum Applies to: Class I, II, III, V & IX expenses Calendar Year Deductible Individual Family Benefit Highlights

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

50% No Deductible

50% No Deductible

50% No Deductible

50% No Deductible

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

Class I: Diagnostic & Preventive Oral Evaluations, Prophylaxis: routine cleanings, X-rays: routine, X-rays: non-routine, Fluoride Application, Sealants: per tooth, Space Maintainers: non-orthodontic

Class II: Basic Restorative Restorative: fillings Oral, Endodontics: minor and major, Periodontics: minor and major, Oral Surgery: minor and major, Anesthesia: general/IV sedation, Repairs: bridges, crowns, and inlays, Repairs: dentures, Dental Relines, rebases and Adjustments, Emergency Care to Relieve Pain

Class III: Major Restorative Inlays and Onlays, Prosthesis Over Implant, Crowns: prefabricated stainless steel / resin, Crowns: permanent cast and porcelain, Bridges and Dentures

Class IV: Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,500

Class IX: Implants

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Dental Insurance

EMPLOYEE BENEFITS

Cigna LOW PLAN Network Options

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Reimbursement Levels

Based on Contracted Fees

Maximum Allowable Charge

Calendar Year Benefits Maximum Applies to: Class I, II, III, V & IX expenses

$750

Calendar Year Deductible Individual Family

$100 $300

Benefit Highlights

$750

$100 $300

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

Class I: Diagnostic & Preventive Oral Evaluations, Prophylaxis: routine cleanings, X-rays: routine, Fluoride Application, Sealants: per tooth, Space Maintainers: non-orthodontic

Class II: Basic Restorative Restorative: fillings, X-rays: non-routine, Emergency Care to Relieve Pain

Class III: Major Restorative Inlays and Onlays, Prosthesis Over Implant, Crowns: prefabricated stainless steel/resin, Crowns: permanent cast and porcelain, Bridges and Dentures, Oral Surgery: all except simple extractions, Extractions of Impacted Teeth, Anesthesia: general and IV sedation, Endodontics: minor and major, Periodontics: minor and major, Repairs: bridges, crowns and inlays, Repairs: dentures, Dental Relines, Rebases and Adjustments

Employee Employee + Spouse Employee + Child(ren) Family

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Dental High Plan $36.66 $77.93 $88.62 $127.57

Low Plan $21.11 $46.05 $51.14 $76.09

Vision Insurance

EMPLOYEE BENEFITS

Superior Vision ABOUT VISION Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

How to Print your Vision ID Card: You can request your vision id card by contacting Superior Vision directly at 800-507-3800. You can also go to www.superiorvision.com and register/login to access your account by clicking on “Members” at the top of the page. You can also download the Superior Vision mobile app on your smart phone.

Copays Exam Eyewear1

$10 $25

Services/frequency Exam 12 months Frame 24 months Lenses 12 months Contact lenses 12 months

Monthly Premiums Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$7.64 $13.00 $13.78 $20.64

(based on date of service)

In-network

Out-of-network

Discount features

Covered in full

Up to $35 retail

$125 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

Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchase 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 les “extras” such a tints and coatings. Eyewear purchase from a Walmart Vision Center does not qualify for this addition discount because of Walmart’s “Always Low Prices” policy.

Exam Frames Lenses (standard) per pair

Progressive Lenticular Contact lenses

2

Medically necessary contact lenses

See description

Up to $45 retail 3

Up to $45 retail

Covered in full

Up to $80 retail

$150 retail allowance

Up to $80 retail

Covered in full

UP to $150 retail

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 lines trifocal amounts; 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 eyeglasses and frames benefit.

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Disability Insurance The Hartford

EMPLOYEE BENEFITS

ABOUT DISABILITY 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

What is Educator Disability Insurance?

Educator Disability insurance is a hybrid that combines features of short-term and long-term disability into one plan.

Disability insurance provides partial income protection if you are unable to work due to a covered accident or illness. The plan gives you flexibility to be able to choose an amount of coverage and waiting period that suits your needs.

Eligibility: You are eligible if you are an active employee who works at least 15 hours per week on a regularly scheduled basis.

Enrollment: You can enroll in coverage within 31 days of your date of hire or during your annual enrollment period.

Effective Date: Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

Actively at Work: 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. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are 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.

Benefit Amount: You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66 2/3% of your current monthly earnings. Earnings are defined in The Hartford’s contract with your employer Elimination Period: You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a disability benefit payment. The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin. For those employees electing an elimination period of 30 days or less, if you are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization.

Definition of Disability: Disability is defined as 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 conditions covered by the insurance, and as a result, your current monthly earnings are 80% or less of your predisability earnings. One you have been disabled for 24 months, you must be prevented from performing one or more essential duties of any occupation, and as a result, your monthly earnings are 66 2/3% or less of your pre-disability earnings 22

Disability Insurance

EMPLOYEE BENEFITS

The Hartford

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

Disability

Elimination Period

per $100 in benefit

0/7

$3.81

14/14

$3.22

30/30

$2.79

60/60

$2.28

90/90

$1.31

180/180

$0.94

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Cancer Insurance

EMPLOYEE BENEFITS

APL ABOUT CANCER 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

Treatment for cancer is often lengthy and expensive. While your health insurance helps pay the medical expenses for cancer treatment, it does not cover the cost of non-medical expenses, such as out-of-town treatments, special diets, daily living and household upkeep. In addition to these non-medical expenses, you are responsible for paying your health plan deductibles and/or coinsurance.

Cancer insurance through APL pays a benefit directly to you to help with expenses associated with cancer treatment.

Employee Employee + Spouse Employee + Child(ren) Family

Low $14.80 $26.40 $20.60 $26.40

Cancer Monthly Rates Low + ICU Rider $17.80 $32.70 $24.80 $32.70

High $29.40 $51.50 $40.40 $51.50

High + ICU Rider $32.40 $57.80 $44.60 $57.80

Summary of Benefits Benefits Radiation Therapy/Chemotherapy/ Immunotherapy Benefit Hormone Therapy Benefit Surgical Schedule Benefit Anesthesia Benefit Hospital Confinement Benefit

Low Plan $500 per calendar month of treatment

$50 per treatment, up to 12 per calendar year $1,600 max per operation; $15 per surgical unit 25% of the amount paid for covered surgery $100 per day 1-90 days; $100 per day, 91+ days in lieu of other benefits US Government/Charity Hospital/ $100 per day in lieu of most other benefits HMO Outpatient Hospital or Ambulatory $200 per day of surgery Surgical Center Benefit Drugs & Medicine Benefit $150 per confinement Inpatient Drugs & Medicine Benefit $50 per prescription, up to $50 per cal month Outpatient Transportation & Outpatient $0.50 per mile per round trip Lodging Benefit $100 per day, up to 100 days per calendar year 24

High Plan $1,500 per calendar month of treatment

$50 per treatment, up to 12 per calendar year $4,800 max per operation; $45 per surgical unit 25% of the amount paid for covered surgery $300 per day 1-90 days; $300 per day, 91+ days in lieu of other benefits $300 per day in lieu of most other benefits $600 per day of surgery $150 per confinement $50 per prescription, up to $150 per cal month $0.50 per mile per round trip $100 per day, up to 100 days per calendar year

Cancer Insurance

EMPLOYEE BENEFITS

APL Summary of Benefits (cont’d) Benefits Low Plan Family Member Transportation & $0.50 per mile per round trip Lodging Benefit $100 per day, up to 100 days per calendar year Blood, Plasma & Platelets Benefit $150 per day, up to $7,500 per calendar year Bone Marrow/Stem Cell Transplant Autologous - $500 per calendar year Non-Autologous - $1,500 per calendar year Experimental Treatment Benefit Pays as any non-experimental benefit Attending Physician Benefit $30 per day of confinement Surgical Prosthesis Benefit $1,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max Hair Prosthesis Benefit $50 per hair prosthetic, 2 lifetime max Dread Disease Benefit $100 per day, 1-90 days of hospital confinement Hospice Care Benefit $50 per day, $9,000 lifetime max Inpatient Special Nursing Services $150 per day of confinement Ambulance Ground Benefit $200 per ground trip Ambulance Air Benefit $2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air) Extended Care Benefit $100 per day Home Health Care Benefit $100 per day Second & Third Surgical Opinions $300 per diagnosis; additional $300 if third opinion required Waiver of Premium Premium waived after 90 days of primary insured continuous total disability due to cancer Physical/Speech Therapy Benefit $25 per visit, up to 4 visits per calendar month, $1,000 lifetime max Riders Diagnostic Testing Benefit Rider $50; 1 person, per calendar year Critical Illness Rider: Cancer Only $2,500 lump sum benefit Optional Benefit Rider Intensive Care Unit Rider Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

High Plan $0.50 per mile per round trip $100 per day, up to 100 days per calendar year $250 per day, up to $12,500 per calendar year Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year Pays as any non-experimental benefit $50 per day of confinement $3,000 per device (includes surgical fee); max 2 device per site, 2 lifetime max $50 per hair prosthetic, 2 lifetime max $300 per day, 1-90 days of hospital confinement $180 per day, $18,000 lifetime max $150 per day of confinement $200 per ground trip $2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air) $300 per day $300 per day $300 per diagnosis; additional $300 if third opinion required Premium waived after 90 days of primary insured continuous total disability due to cancer $25 per visit, up to 4 visits per calendar month, $1,000 lifetime max $50; 1 person, per calendar year $2,500 lump sum benefit Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Pre-Existing Condition Limitations Apply, see plan documents on benefit website for details and limitations.

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Basic Life and AD&D

EMPLOYEE BENEFITS

Lincoln Financial Group ABOUT LIFE AND AD&D 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd Who is eligible for this coverage?

All eligible full-time and part-time employees excluding substitute teachers

What is the coverage amount?

Life Coverage: Your employer is providing you with $15,000 AD&D Coverage: Benefit is dependent upon injury: Loss Loss of Life Loss of one Member (Hand, Eye, Foot) Loss of Two or More Members

Benefit for Common Carrier Accident 2 Times Principal Sum Principal Sum

Benefits for other Covered Accident Principal Sum ½ Principal Sum

2 Times Principal Sum

Principal Sum

When is coverage effective?

Your coverage will become effective the first of the month following the date you become eligible.

Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff or leave of absence on the date that insurance would otherwise become effective.

Can I keep if I leave my employer?

Conversion is available with anyone’s group life insurance terminates or reduced due to: the insured Person’s termination of employment or membership in an eligible class, a reduction in the amount of coverage due to ae, a change in class or a policy amendment, termination of this policy, the insured Person’s death, divorce, annulment or a covered dependent’s ceasing to be an eligible dependent.

Includes the option to convert all of part of the terminated insurance without Evidence of Insurability.

Living Benefit

An Accelerated Death Benefits is available when the insured Person’s life insurance benefit is $2,000 or more. If the insured Person is diagnosed terminally ill due to a sickness or injury at least 12 months after the life insurance takes effect or on the date of the injury which results in terminal illness, then part of his or her life insurance benefit can be pair prior to death (subject to state law).

Terminally ill means the insured Person’s medical condition is expected to result in death within 24 months, despite appropriate medical treatment.

The amount of the Accelerated Death Benefit is subject to: a minimum of $1,000 or 10% of the insured Person’s life insurance coverage, whichever is more and a maximum of $50,000 or 75% of the insured Person’s life insurance coverage, whichever is less.

Waiver of Premium

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If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability after a 9 month waiting period.

Basic Life and AD&D Lincoln Financial Group Additional AD&D Benefits

EMPLOYEE BENEFITS

Coma Benefit – An additional benefit equal to 5% of the insured employee’s principal sum will be paid if the insured employee is in a coma as a result of an accident covered under the policy. The coma must begin with 365 days of the accident and the insured mus remain in the coma for at least 31 days for the benefits to be paid. Coma means benign in a state of complete mental unresponsiveness, with no evidence of appropriate response to stimulation.

Plegia Benefit – If the ensured employee sustains an accidental bodily injury that directly causes paraplegia )paralysis of both legs) or hemiplegia (paralysis of arm and leg on the same side), a benefits equal to 50% of the insured’s principal sum will be paid. If the injury directly causes quadriplegia) paralysis of both arms and both legs), a benefit euql to 100% of the insured’s principal sum will be paid.

If the plegia results from a common carrier accident, the plegia benefits will be doubled. The injury must cause plegia within 365 days of the accident for benefits to be paid. If the insured sustains more than one loss resulting form the same accident, benefits will not exceed the maximum amount allowed for that person’s combined losses. Paralysis means complete and irrevocable loss of use of an arm or leg (without severance).

Repatriation Benefit – As a result of the insured employee’s death, an additional benefits will be paid if the insured dies from a covered accident at least 150 miles from home and the beneficiary incurs expenses for the preparation and transportation of the insured’s body to a mortuary. The benefit is equal to the expenses incurred for the preparation and transportation of the insured’s body subject to a maximum of $5,000.

Education Benefit - In the event of the insured person's death as a result of a covered accident, an additional benefit equal to 5% of the insured's principal sum / subject to a maximum of $5,000, will be paid to an eligible dependent child to cover the cost of post-secondary education. Benefits will be paid for up to 4 years as long as the dependent is a full-time student attending an accredited college or university or vocational school and incurs expenses for tuition, fees, room and board, or other costs paid to (or certified by) the school. The dependent child must enroll before reaching age 25. If the Insured Person has no dependent child who is eligible for this benefit as described above, then an additional $1,000 will be paid to the beneficiary.

Spouse Training Benefit - In the event of the insured person's death as a result of a covered accident, an additional benefit equal to 5% of the insured's principal sum / subject to a maximum of $5,000, will be paid to an insured person's spouse to cover the cost of classes taken to retrain or refresh skills needed for employment. Benefits will be paid for one year as long as the spouse incurs expenses payable directly to (or approved or certified by) the school and is enrolled in classes within 365 days of the accident. If the Insured Person has no spouse who is eligible for the benefit as described above, an additional benefit of $1,000 will be paid to the beneficiary.

Child Care Benefit - In the event of the insured person's death as a result of a covered accident, an additional benefit equal to 5% of the insured's principal sum / subject to a maximum of $5,000, will be paid for an eligible dependent that attends a licensed child care facility on a regular basis. This benefit will be paid for up to four consecutive years or until the child's 13th birthday, whichever comes first. If the Insured Person has no dependent child eligible for this benefit, an additional benefit of $1,000 will be paid to the beneficiary.

Do my life insurance benefits decrease with age?

Coverage amounts will reduce according to the following schedule: Age: 70

Insurance amount reduces to: 50% of original amount

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Voluntary Life and AD&D Lincoln Financial Group

EMPLOYEE BENEFITS

ABOUT LIFE AND AD&D 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

Voluntary Life Employee Benefits Who Is Eligible? All Eligible Full-Time and Part-Time Employees Excluding Substitute Teachers Coverage Amount: Increments of $10,000. Not to exceed 7 times the employee's annual salary.

Rounded to the next higher $10,000.

Guarantee Issue Amount Evidence of Insurability will be required for Initial Insurance Amounts in excess of $250,000 and for insurance amounts that are increased after initial enrollment by more than 4 benefit increments.

Minimum Coverage Amount: $10,000 Maximum Coverage Amount*: $500,000 Definition of Earnings: Basic Annual Earnings Excluding Overtime, Bonuses, & Commission Conversion Privilege: Available when insurance terminates Additional Features Included: Accelerated Death Benefit (Living Benefit), Waiver of Premium (Extension of Death Benefit), Continuation of Coverage (Portability)

The benefit equals the amount of the dependent life insurance in effect on the date of such death. Upon receipt of satisfactory proof of a dependent’s death while insured under the policy, the death benefit will be paid to the Insured Person.

Benefit Reduction Schedule Voluntary Life Employee and Spouse Reduction Schedule: Age Reduction 70 50% Terminate upon the employee’s retirement.

Conversion privilege: Conversion is available when anyone's group life insurance terminates or reduces due to: • the Insured Person's termination of employment or membership in an eligible class; • a reduction in the amount of coverage due to age, a change in class, or a policy amendment; • termination of this policy; • the Insured Person's death, divorce or annulment; or • a covered Dependent's ceasing to be an eligible dependent.

Voluntary Life - Dependent Benefits • That person has the option to convert all or part of the Spouse Coverage Amount*: Increments of $10,000. Not to exceed terminated insurance without Evidence of Insurability. The 7 times the employee's annual salary or 100% of the employee's conversion may be made to any Individual Life Policy then benefit amount. Rounded to the next higher $5,000. provided by Lincoln Financial Group. To purchase a Spouse Minimum Coverage Amount: $10,000 conversion policy, application and the first premium Spouse Maximum Coverage Amount: $500,000 payment must be made within the time period specified in Guarantee Issue Amount: Evidence of Insurability will be required the policy. for Initial Insurance Amounts in excess of $60,000 and for insurance amounts that are increased after initial enrollment by Living benefit: An Accelerated Death Benefit is available when the Insured Person’s life insurance benefit is $2,000 or more. If the more than 4 benefit increments.

Insured Person is diagnosed terminally ill due to a sickness or Child Age: Day 1 to less than 26 years (or 26 years if unmarried, & injury at least 12 months after life insurance takes effect or on a full-time student) the date of an injury which results in Terminal Illness, then part of Children Coverage Amount: Increments of $2,500. his or her life insurance benefit can be paid prior to death Children Coverage Minimum Amount: $2,500 (subject to state law).

Children Coverage Maximum Amount: $10,000 Terminally ill means the Insured Person’s medical condition is expected to result in death within 12 Months, despite *Spouse coverage is only available if the employee is insured for appropriate medical treatment. voluntary coverage.

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Voluntary Life and AD&D Lincoln Financial Group The amount of the Accelerated Death Benefit is subject to: • a minimum of $10,000 or 10% of the Insured Person’s life insurance coverage, whichever is more; and • a maximum of $250,000 or 75% of the Insured Person’s life insurance coverage, whichever is less.

EMPLOYEE BENEFITS

Voluntary AD&D Benefit Overview

Eligible employees may elect to insure his/her dependents. The amount of AD&D Insurance for Dependents is equal to a percentage of the employee’s AD&D Insurance, as follows: Who Is Eligible? All Eligible Full-Time and Part-Time Employees Excluding Substitute Teachers Waiver of Premium (Extension of Death Benefit): An Insured Employee coverage amount: Increments of $10,000. Not to Person’s Life Insurance (and any Dependent Life Insurance) will exceed 7 times the employee's annual salary Rounded to the be continued without payment of premium, if the Insured next higher $1,000 Person: Employee minimum coverage amount: $10,000 • Becomes Totally Disabled while insured under the policy and Employee maximum coverage amount: $500,000 before age 60 Employee age reductions: Reduce by 50% at age 70; Terminate at • Remains Totally Disabled for at least 6 months; and retirement • Submits satisfactory proof within the time period specified in Employee, Spouse and Child(ren): Spouse Coverage Amount: 40% the policy. of the employee's amount of coverage Total Disability shall be defined as shown in the policy. The Employee, Spouse and Child(ren): Child(ren) Coverage Amount: continued life insurance will be subject to the age reductions 10% of the employee's amount of coverage shown in the Schedule of Insurance. The continued life insurance Employee and Spouse Only: Spouse Coverage Amount Only: 50% will terminate when the Insured Person: of the employee's amount of coverage • Ceases to be Totally Disabled; Spouse age reductions: Reduce by 50% at age 70; Terminate upon • Insured Person fails to take a required medical exam or to employment or retirement submit additional proof as requested; Employee and Child(ren): Child(ren) Coverage Amount Only: 15% • Insured Person becomes insured under an individual of the employee's amount of coverage conversion policy; or Optional Benefits: Included • Attains Social Security Normal Retirement Age (SSNRA).

Key coverage highlights • Provides a cash benefit to your loved ones in the event of Portability: your accidental death • Automatically included with both employee and spouse • Provides an additional cash benefit to your loved ones if you coverage. die — or to you if you lose a limb or your eyesight — in a • Allows employees and spouses to keep their Life, Accidental covered accident Death and Dismemberment and Dependent Children insurance in force even after employees leave your Voluntary Group Life - per $10,000 in coverage employment.

Age Employee Spouse • Life insurance coverage must be in-force at least 12 months < 29 $0.45 $0.45 prior to an employee's termination.

30-34 $0.55 $0.55 • Rates remain the same as those in effect at the time of 35-39 $0.65 $0.65 termination and will be adjusted in the same way as your 40-44 $1.00 $1.00 group rates are adjusted.

45-49 $1.55 $1.55 • The employee must not be terminating due to total disability 50-54 $2.40 $2.40 or retirement at the Social Security Normal Retirement Age 55-59 $3.67 $3.67 (SSNRA).

60-64 $5.89 $5.89 An insured must apply for the portability option in order to 65-69 $9.79 $9.79 actually keep the coverage. Written application along with the 70-74 $14.61 $14.61 required premium must be made no later than 31 days after the 75+ $26.72 $26.72 date the insurance would normally terminate.

Voluntary Group Life - Child(ren) - $10,000 in coverage Dependent Life - Conversion privilege: 0-26 $1.50 Conversion may be available to dependents – check the Spouse rates based on Employee's age. certificate to find out more.

Voluntary AD&D - per $1,000 Employee Only $0.017 Family $0.031

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Individual Life Insurance 5 Star

EMPLOYEE BENEFITS

ABOUT INDIVIDUAL LIFE Individual insurance is a policy that covers a single person and is intended to meet the financial needs of the beneficiary, in the event of the insured’s death. This coverage is portable and can continue after you leave employment or retire.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

Family Protection Plan with 5Star Life Insurance offers individual insurance coverage to age 121. The plan includes a Terminal Illness Acceleration of Benefit and a Qualify of Life Benefit.

TERMINAL ILLNESS ACCELERATION OF BENEFITS Coverage that pays 30% of the coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months.

QUALITY OF LIFE Optional benefit that accelerates a portion of the death benefit on a monthly basis, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or • Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision.

PORTABLE Coverage continues with no loss of benefits or increase in cost if employment terminates after the first premium is paid. We simply bill the employee directly. CONVENIENCE Easy payments through payroll deduction.

FAMILY PROTECTION Coverage is available for spouses and financially dependent children, even if the employee doesn’t elect coverage on themselves. * Financially dependent children 14 days to 23 years old.

PROTECTION TO COUNT ON Within one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions.

Should you need to file a claim, contact 5Star directly at (866) 863-9753. *Quality of Life not available ages 66-70. Quality of Life benefits not available for children Child life coverage available only on children and grandchildren of employee (age on application date: 14 days through 23 years).$7.15 monthly for $10,000 coverage per child.

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Individual Life Insurance 5 Star Age on Eff. Date 18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66* 67* 68* 69* 70*

$10,000 $9.90 $9.91 $9.98 $10.08 $10.23 $10.43 $10.64 $10.87 $11.11 $11.40 $11.72 $12.08 $12.46 $12.88 $13.33 $13.83 $14.38 $14.98 $15.60 $16.26 $16.93 $17.67 $18.43 $19.19 $20.02 $20.93 $21.94 $23.11 $24.42 $25.88 $27.44 $29.19 $30.99 $32.84 $34.74 $36.71 $38.77 $40.93 $43.22 $45.72 $48.50 $49.13 $52.62 $56.58 $61.09 $66.18

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts $20,000 $30,000 $40,000 $50,000 $75,000 $100,000 $13.28 $16.68 $20.07 $23.46 $31.94 $40.42 $13.34 $16.75 $20.16 $23.59 $32.13 $40.66 $13.46 $16.96 $20.44 $23.92 $32.62 $41.34 $13.66 $17.26 $20.84 $24.42 $33.37 $42.34 $13.95 $17.68 $21.40 $25.13 $34.44 $43.75 $14.35 $18.28 $22.20 $26.12 $35.94 $45.75 $14.76 $18.90 $23.04 $27.16 $37.50 $47.84 $15.23 $19.61 $23.97 $28.34 $39.25 $50.17 $15.72 $20.33 $24.93 $29.55 $41.06 $52.58 $16.30 $21.20 $26.10 $31.00 $43.26 $55.50 $16.93 $22.16 $27.37 $32.59 $45.63 $58.67 $17.65 $23.23 $28.80 $34.37 $48.31 $62.25 $18.44 $24.40 $30.36 $36.34 $51.25 $66.16 $19.25 $25.63 $32.00 $38.38 $54.32 $70.25 $20.17 $27.00 $33.83 $40.67 $57.76 $74.83 $21.15 $28.48 $35.80 $43.13 $61.44 $79.75 $22.25 $30.13 $38.00 $45.87 $65.57 $85.25 $23.46 $31.96 $40.44 $48.92 $70.12 $91.34 $24.70 $33.81 $42.90 $52.00 $74.75 $97.50 $26.02 $35.78 $45.53 $55.30 $79.69 $104.08 $27.37 $37.80 $48.23 $58.67 $84.75 $110.83 $28.83 $40.00 $51.17 $62.33 $90.26 $118.17 $30.35 $42.28 $54.20 $66.13 $95.94 $125.75 $31.88 $44.58 $57.27 $69.96 $101.69 $133.42 $33.55 $47.08 $60.60 $74.13 $107.94 $141.75 $35.36 $49.81 $64.24 $78.67 $114.75 $150.84 $37.39 $52.83 $68.26 $83.71 $122.32 $160.91 $39.74 $56.35 $72.96 $89.59 $131.13 $172.66 $42.33 $60.26 $78.17 $96.09 $140.87 $185.67 $45.27 $64.65 $84.03 $103.42 $151.88 $200.33 $48.37 $69.31 $90.23 $111.17 $163.50 $215.83 $51.87 $74.56 $97.23 $119.92 $176.63 $233.33 $55.49 $79.98 $104.46 $128.96 $190.19 $251.41 $59.19 $85.53 $111.86 $138.21 $204.06 $269.91 $62.97 $91.21 $119.43 $147.67 $218.25 $288.83 $66.94 $97.15 $127.36 $157.59 $233.13 $308.66 $71.05 $103.33 $135.60 $167.88 $248.57 $329.25 $75.37 $109.80 $144.23 $178.67 $264.75 $350.83 $79.95 $116.68 $153.40 $190.13 $281.94 $373.75 $84.93 $124.16 $163.37 $202.59 $300.62 $398.67 $90.50 $132.51 $174.50 $216.50 $321.50 $426.50 $91.75 $134.38 $177.00 $219.63 $326.19 $432.75 $98.73 $144.85 $190.97 $237.08 $352.38 $467.67 $106.67 $156.75 $206.83 $256.92 $382.13 $507.33 $115.68 $170.28 $224.87 $279.46 $415.94 $552.42 $125.85 $185.53 $245.20 $304.88 $454.06 $603.25

EMPLOYEE BENEFITS

$125,000 $48.89 $49.21 $50.04 $51.29 $53.07 $55.56 $58.16 $61.09 $64.11 $67.75 $71.71 $76.18 $81.09 $86.19 $91.92 $98.06 $104.94 $112.54 $120.25 $128.48 $136.92 $146.09 $155.56 $165.15 $175.57 $186.92 $199.52 $214.21 $230.46 $248.80 $268.17 $290.04 $312.64 $335.77 $359.42 $384.21 $409.94 $436.92 $465.56 $496.71 $531.50 $539.31 $582.96 $632.54 $688.90 $752.44

$150,000 $57.38 $57.75 $58.76 $60.26 $62.38 $65.38 $68.50 $72.01 $75.63 $80.00 $84.76 $90.13 $96.00 $102.13 $109.00 $116.38 $124.63 $133.76 $143.01 $152.88 $163.00 $174.00 $185.38 $196.88 $209.38 $223.01 $238.13 $255.75 $275.26 $297.25 $320.51 $346.76 $373.88 $401.63 $430.01 $459.75 $490.63 $523.00 $557.38 $594.76 $636.51 $645.88 $698.25 $757.75 $825.38 $901.63 31

Flexible Spending Account (FSA) NBS

EMPLOYEE BENEFITS

ABOUT FSA A Flexible Spending Account allows you to pay for eligible healthcare expenses with a pre-loaded debit card. You choose the amount to set aside from your paycheck every plan year, based on your employer’s annual plan limit. This money is use it or lose it within the plan year (unless your plan contains a $500 rollover or grace period provision).

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

Health Care FSA

Dependent Care FSA

The Health Care FSA covers qualified medical, dental and vision expenses for you or your eligible dependents. You may contribute up to $2,850 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include: • Dental and vision expenses • Medical deductibles and coinsurance • Prescription copays • Hearing aids and batteries You may not contribute to a Health Care FSA if you enrolled in a High Deductible Health Plan (HDHP) and contribute to a Health Savings Account (HSA).

The Dependent Care FSA helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full time. You can use the account to pay for day care or baby sitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you must be a single parent or you and your spouse must be employed outside the home, disabled or a full-time student.

How the Health Care FSAs Work

•

Dependent Care FSA Guidelines

You can access the funds in your Health Care FSA two different ways: • • Use your NBS Debit Card to pay for qualified expenses, doctor visits and prescription copays.

• Pay out-of-pocket and submit your receipts for • reimbursement:  Fax – 844-438-1496  Email – service@nbsbenefits.com  Online – my.nbsbenefits.com •  Call for Account Balance: 855-399-3035  Mail: PO Box 6980 West Jordan, UT 84084

Contact NBS • • • • 32

Hours of Operation: 6:00 AM – 6:00 PM MST, Mon-Fri Phone: (800) 274-0503 Email: service@nbsbenefits.com Mail: PO Box 6980 West Jordan, UT 84084

Overnight camps are not eligible for reimbursement (only day camps can be considered).

If your child turns 13 midyear, you may only request reimbursement for the part of the year when the child is under age 13.

You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care.

The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.

Important FSA Rules •

The maximum per plan year you can contribute to a Health Care FSA is $2,850. The maximum per plan year you can contribute to a Dependent Care FSA is $5,000 when filing jointly or head of household and $2,500 when married filing separately.

Flexible Spending Account (FSA) NBS • • • •

EMPLOYEE BENEFITS

You cannot change your election during the year unless you experience a Qualifying Life Event.

You can continue to file claims incurred during the plan year for another 90 days from August 31st.

Your Health Care FSA debit card can be used for health care expenses only. It cannot be used to pay for dependent care expenses.

The IRS has amended the “use it or lose it rule” to allow you to carry-over up to $570 in your Health Care FSA into the next plan year. The carry-over rule does not apply to your Dependent Care FSA.

Over-the-Counter Item Rule Reminder Health care reform legislation requires that certain over-the-counter (OTC) items require a prescription to qualify as an eligible Health Care FSA expense. You will only need to obtain a one-time prescription for the current plan year. You can continue to purchase your regular prescription medications with your FSA debit card. However, the FSA debit card may not be used as payment for an OTC item, even when accompanied by a prescription.

Flexible Spending Accounts Account Type

Health Care FSA

Dependent Care FSA

Eligible Expenses Most medical, dental and vision care expenses that are not covered by your health plan (such as copayments, coinsurance, deductibles, eyeglasses and doctor-prescribed over-the-counter medications) Dependent care expenses (such as day care, after-school programs or elder care programs) so you and your spouse can work or attend school full-time

Annual Contribution Limits

Benefit

$2,850

Saves on eligible expenses not covered by insurance, reduces your taxable income

$5,000 single $2,500 if married and filing separate tax returns

Reduces your taxable income

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Hospital Indemnity The Hartford

EMPLOYEE BENEFITS

ABOUT HOSPITAL INDEMNITY This is an affordable supplemental plan that pays you should you be inpatient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance.

For full plan details, please visit your benefit website: www.mybenefitshub.com/jacksonvilleisd

Hospital Indemnity Low High Employee $17.50 $30.24 Employee + Spouse $32.16 $55.29 Employee + Child(ren) $29.92 $51.31 Family $46.64 $79.86 Plan Information Low High Coverage Type: On and Off Job 24 hour 24 hour Covered Events Illness and injury Illness and injury HSA Compatible Yes Yes Benefits Low High First Day Hospital Confinement – Up to 1 day per year $1,000 $2,000 Daily Hospital Confinement (Day 2+) – Up to 30 days per year $100 $100 Daily ICU Confinement (Day 2+) – Up to 10 days per year $200 $200 Features Low High Ability Assist EAP = 24/7/365 access to help for financial, legal or emotional issues Included Included HealthChampion – administrative and clinical support following serious illness or injury Included Included

Coverage Information – You have a choice of two hospital indemnity plans, which allows you the flexibility to enroll for the coverage the best meets your needs.

Benefits amounts are based on the plan in effect for you or an insured dependent at the time the covered event occurs. Unless otherwise noted, the benefit amounts payable under each plan re the same for you and your dependent(s).

WHEN CAN I ENROLL? You may enroll during an y scheduled IS THIS COVEAGE HSA COMPATIBLE? If you – or any dependent(s) enrollment period or within 31 days of the date you have a – currently participate in a Health Savings Account (HSA) or if you change in family status. plan to do so in the future, you should be aware that the IRS WHEN DOES THIS INSURANCE BEGIN? Insurance will become limits the types of supplemental insurance you may have in effective in accordance with the terms of the certificate (usually addition to a HSA, while still maintaining the tax-exempt status of the first day of the month following the date you elect coverage). the HSA. You must be actively at work with your employer on the day your This plan design was designed to be compatible with HSAs. coverage takes effect. Your spouse and child(ren) must be However, if you have or plan to open an HSA, please consult you performing normal activities and not be confined (at home or in a tax and legal advisors to determine which supplemental benefits hospital/care facility). may be purchase by employees with an HSA. WHEN DOES THIS INSURANCE END? This insurance will end when WHO IS ELIGIBLE? You are eligible for this insurance if you are an your dependents no longer satisfy the applicable eligibility active full-time employee who works at least 20 hours per week conditions or when you reach the age of 80, premium is unpaid, on a regularly scheduled basis and are less than age 80. Your you are not longer actively working, you leave your employer or spouse and child(ren) are also eligible for coverage. Any child the coverage is no longer offered. (ren) must be under age 26.

CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO AM I GUARANTEED COVERAGE? This insurance is guaranteed LONGER A MEMBER OF THIS GROUP? Yes, you can take this issue. It is available without having to provide information about coverage with you. Your spouse/partner may also continue you or your family’s health. insurance in certain circumstances.

Asked & Answered

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Notes

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2022 - 2023 Plan Year

Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the Jacksonville ISD Benefits Website. This summary does not replace or amend the underlying plan documentation. In the event of a discrepancy between this summary and the plan documentation the plan documentation governs. All plans and benefits described in this summary may be discontinued, increased, decreased, or altered at any time with or without notice.

Rate Sheet General Disclaimer: The rate information provided in this guide is subject to change at any time by your employer and/or the plan provider. The rate information included herein, does not guarantee coverage or change or otherwise interpret the terms of the specific plan documentation, available at the Jacksonville ISD Benefits Website, which may include additional exclusions and limitations and may require an application for coverage to determine eligibility for the health benefit plan. To the extent the information provided in this summary is inconsistent with the specific plan documentation, the provisions of the specific plan documentation will govern in all cases.

WWW.MYBENEFITSHUB.COM/JACKSONVILLEISD 36