2016 Benefit Guide Angleton ISD by Higginbotham Public Sector

ANGLETON ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2016 - 8/31/2017 www.mybenefitshub.com/angletonisd

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. HSA vs FSA Comparison TRS-ActiveCare Aetna HSA Bank Health Savings Account Cigna Dental Superior Vision The Hartford Long-Term Disability APL Cancer Unum Critical Illness One America Life and AD&D One America EAP 5 Star FPP TI with Quality of Life Rider NBS Flexible Spending Account MDLIVE Telehealth LegalShield ID Theft Protection

3 4-5 6-11 6 7 8 9 10 11 12-13 14-17 18-21 22-23 24-27 28-31 32-33 34-39 40-41 42-45 46-49 50-51 52-53

FLIP TO... PG. 4 HOW TO ENROLL

PG. 6 YOUR BENEFIT UPDATES: WHATâ&#x20AC;&#x2122;S NEW

PG. 12 YOUR MEDICAL BENEFITS

Benefit Contact Information

Benefit Contact Information BENEFIT ADMINISTRATORS

VISION

FLEXIBLE SPENDING ACCOUNT (FSA)

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

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

ANGLETON ISD ADMINISTRATOR

DISABILITY

TELEHEALTH

Francene Lindsey (979) 864-8057 flindsey@angletonisd.net

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

MD Live (888) 365-1663 www.consultmdlive.com

TRS ACTIVECARE MEDICAL

CANCER

IDENTITY THEFT

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

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

Legal Shield (800) 654-7757 www.legalshield.com

HEALTH SAVINGS ACCOUNT (HSA)

CRITICAL ILLNESS

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

UNUM (866) 679-3054 www.unum.com

DENTAL

FAMILY PROTECTION PLAN â&#x20AC;&#x201C; TERM LIFE WITH QUALITY OF LIFE RIDER

CIGNA (800) 244-6224 www.mycigna.com

5Star Life Insurance Company (866) 863-9753 www.5starlifeinsurance.com

How to Enroll On Your Device Enrolling in your benefits just got a lot easier! Text “angleton” to 313131 to receive everything you

TEXT

need to complete your enrollment.

“angleton” Avoid typing long URLs and scan

directly to your benefits website,

313131

to access plan information, benefit guide, benefit videos, and more!

TRY ME

SCAN:

On Your Computer Access THEbenefitsHUB from your

Our online benefit enrollment

computer, tablet or smartphone!

platform provides a simple and easy to navigate process. Enroll at your own pace, whether at home or at work. www.mybenefitshub.com/ angletonisd delivers important benefit information with 24/7 access, as well as detailed plan information, rates and product videos.

! 4

Open Enrollment Tip For your User ID: 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.

Go to:

Click Login

Enter Username & Password

www.mybenefitshub.com/angletonisd

All login credentials have been RESET to the default described below:

Username:

Sample Username

lincola1234 Sample Password

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.

lincoln1234

If you have six (6) or less characters in your last name,

If you have trouble

use your full last name, followed by the first letter of

logging in, click on the

your first name, followed by the last four (4) digits of

“Login Help Video”

your Social Security Number.

for assistance.

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

Click on “Enrollment Instructions” for more information about how to enroll. 5

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  Financial Benefit Services (FBS) is the new Third Party

Administrator for the Angleton ISD. FBS will conduct the annual enrollment and provide benefit support for Angleton ISD employees. New benefits and insurance providers have been selected by the district to provide the best in insurance coverage at affordable rates for you as an employee of Angleton ISD.  Benefit elections will become effective 9/1/2016.

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).  Aetna remains the carrier for TRS Medical Plans:

who are between 55-65, there is an additional catch-up provision of $1,000 that can be contributed annually.  NEW FSA ADMINISTRATOR! National Benefit Services is

the new FSA Administrator for Angleton ISD. The 2016 FSA contribution limit is $2550. If you currently participate or are enrolling for the first time in a FSA or a Dependent Care FSA with Angleton ISD, you will receive new debit cards with the new provider, National Benefit Services by the end of September. Remember, you must re-elect a new contribution amount every year to continue to participate. You can manually submit claims prior to receiving your cards. Find the claim form on the benefits website at www.mybenefitshub.com/ angletonisd. Please note that a $500 rollover will be available for the plan year beginning September 1, 2017.

ActiveCare 1 HD, ActiveCare 2 and ActiveCare Select. All eligible employees, including active, contributing TRS  NEW! MDLive is the new provider for Telehealth. Enjoy members and employees regularly working 10 hours per unlimited phone consultations with a licensed physician week MUST either enroll for coverage or decline for you and your household for $10 per month. A coverage in the Benefits HUB. For comprehensive TRS Welcome Kit and ID card can be printed from the benefit medical information, visit the website, website at www.mybenefitshub.com/angletonisd.com. www.trsactivecareaetna.com. This benefit is available to you even if you are not enrolled on the medical plan with the district. This  NEW! A Health Savings Account with HSA Bank is a taxbenefit is not to be confused with the Telehealth benefit included in the ActiveCare plans. free savings account available for those employees enrolled in ActiveCare 1 HD. These funds can be used to pay for medical, dental, vision or prescription expenses. The HSA annual contribution maximum is $3,350 for individuals and $6,750 for your family. For individuals

Don’t Forget!  Login and complete your benefit enrollment from 8/1/2016 - 8/22/2016  On-site enrollment assistance will be available at various campuses August 11th, 12th, 15th, 16th,

18th, and 19th. Please contact your Angleton ISD Benefit Office for times and locations.  Add dependents to the system—please bring dependent Social Security numbers and date of birth. 6

SUMMARY PAGES

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

CHANGES IN 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 31 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS 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 adoption. Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents result of a valid change in status event. Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website:

annual enrollment) unless a Section 125 qualifying event occurs.

www.mybenefitshub.com/angletonisd. Click on the benefit plan you need information on (i.e., Dental) and you can find



Changes, additions or drops may be made only during the

the forms you need under 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

ISD benefit website: www.mybenefitshub.com/angletonisd.

included in the dependent profile. Additionally, you must

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

notify your employer of any discrepancy in personal and/or

Dental) and you can find provider search links under the Quick

benefit information.



For benefit summaries and claim forms, go to the Angleton

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.

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.

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.

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.

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 the Angleton ISD 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 2016 benefits become effective on September 1, 2016, you must be actively-at-work on September 1, 2016 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

Through 26

Dental

Cigna

Through 26

Vision

Superior Vision

Through 26

Life

One America

Through 26

Cancer

American Public Life

Through 26

Critical Illness

UNUM

Through 26

AD&D

One America

Through 26

Permanent Life

5 Star

Through 23

If your dependent is disabled, coverage can continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physicianâ&#x20AC;&#x2122;s statement confirming your dependentâ&#x20AC;&#x2122;s disability. Contact your HR/Benefit Administrator to request a continuation of coverage. 9

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2016 please notify your benefits administrator.

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

$1,300 single (2016) $2,600 family (2016) $3,350 single (2016) $6,750 family (2016)

N/A Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO… PG. 14

FLIP TO… PG. 46

FOR HSA INFORMATION

FOR FSA INFORMATION

2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits* Type of Service

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

Out-of-Pocket Maximum (per plan year; does include medical deductible/ any medical copays/coinsurance/ any prescription drug deductible and applicable copays/coinsurance)

$6,550 individual $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual)

$6,850 individual $13,700 family

Coinsurance Plan pays (up to allowable amount) Participant pays (after deductible)

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

$40 consultation fee (applies to deductible and out-of-pocket maximum)

Plan pays 100%

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays

20% after deductible

$100 copay plus 20% after deductible

Inpatient Hospital (preauthorization required) (facility charges) Participant pays

20% after deductible

$150 copay per day plus 20% after deductible ($750 maximum copay per admission)

$150 copay per day plus 20% after deductible($750 maximum copay per admission; $2,250 maximum copay per plan year)

Emergency Room (true emergency use) Participant pays

20% after deductible

$150 copay plus 20% after deductible (copay waived if admitted)

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays

$5,000 copay plus 20% after deductible

Not covered

$5,000 copay (does not apply to out -of-pocket maximum) plus 20% after deductible

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

$0 for generic drugs $200 per person for brand-name drugs

Retail Short-Term (up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $20 $40** 50% coinsurance**

$20 $40** $65**

Retail Maintenance (after first fill; up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $35 $60** 50% coinsurance**

$35 $60** $90**

Mail Order and Retail-Plus (up to a 90-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $45 $105*** 50% coinsurance

$45 $105*** $180***

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

$200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply)

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.

TRS-ActiveCare Plans—Preventive Care Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) 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) www. uspreventiveservicestaskforce.org/Page/Name/uspstf-a-andbrecommendations.

Plan pays 100% (deductible waived)

Plan pays 100% (deductible waived; no copay required)

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling – 8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support – 6 lactation counseling visits per 12 months

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling –8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support –6 lactation counseling visits per 12 months

Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

After deductible, plan pays 80%; participant pays 20%

$60 copay for specialist

$50 copay for specialist

Annual Hearing Examination Participant pays

After deductible, plan pays 80%; participant pays 20%

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

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. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/factsand- features/fact-sheets/ preventive-services-covered-underaca/ index.html#CoveredPreventiveServicesforAdults. For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. (Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling. Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800222-9205. The list may change as FDA guidelines are modified.

Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

About this Benefit A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.

DID YOU KNOW? The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Angleton ISD Benefits Website: www.mybenefitshub.com/angletonisd 14

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 

A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated)Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution.



Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

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

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

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

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder  Age 55 or older (regardless of when in the year an accountholder turns 55)

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

How an HSA works:



 

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

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

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

2016 Annual HSA Contribution Limits Individual = $3,350 Family = $6,750

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

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

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

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

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

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

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

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

CIGNA

Dental

YOUR BENEFITS PACKAGE

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.

DID YOU KNOW?

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.

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

Cigna Dental PPO - Low Option In-Network Out-of-Network Total Cigna DPPO $1,000 - Class I Applies

$1,000 - Class I Applies

$50 per person $150 per family

Based on Reduced Contracted Fees

Based on Maximum Allowable Charge (Innetwork fee level)

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

Monthly PPO Premiums Tier

Rate

EE Only

$22.85

EE + 1 Dependent

$42.52

EE + 2 or more Dependents

$66.16

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

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions

No Waiting Period

50%*

Class III - Major Restorative Care Crowns Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia Annual Maximum: $500 Lifetime Maximum: $1,000

50%*

12 Month Waiting Period 50% Covered for 50% Children & Adults 12 Month Waiting Period

50%*

12 Month Waiting Period 50% Covered for 50% Children & Adults 12 Month Waiting Period

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. *Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to the Contracted Fee Schedule but the dentist may balance bill up to their usual fees.

Dental PPO Procedure

Exclusions and Limitations

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

50% coverage on Class III and IV for 12 months Two per calendar year Two per calendar year 1 per Calendar year for people under 16 Bitewings: 2 per Calendar year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 16. Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions     

              

   

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



comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions andlimitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HP-POL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HPPOL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc.

Dental DHMO DHMO Charge Schedule Service Code

Procedure Description

Patient Charge

D1110

Prophylaxis (cleaning) – Adult (limit 2 per calendar year)

$0.00

D0120

Periodic Oral Evaluation - Established Patient

$0.00

D0150

Comprehensive oral evaluation – New or established patient

$0.00

D0210

X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years)

$0.00

D0274

X-rays (bitewings) – 4 radiographic images

$0.00

D0330

X-rays (panoramic radiographic image) – (limit 1 every 3 years)

$0.00

D1351

Sealant – Per tooth

$11.00

D1510

Space maintainer – Fixed – unilateral

$30.00

D2161

Amalgam – 4 or more surfaces, primary or permanent

$0.00

D6740

Crown – Porcelain/ceramic

$195.00

D6930

Recement fixed partial denture

$0.00

D3330

Molar root canal – Permanent tooth (excluding final restoration)

$275.00

D5110

Full upper denture

$185.00

D9220

General anesthesia – First 30 minutes

$160.00

D7140

Extraction, erupted tooth or exposed root - elevation and/or forceps removal

$6.00

D8670

Periodic orthodontic treatment visit – As part of contract: Children—up to 19th birthday 24-month treatment fee

$1,464.00

Charge per month for 24 months

$61.00

Adults 24-month treatment fee

$2,160.00

Charge per month for 24 months

$90.00

For a complete list of fees and services please visit www.mybenefitshub.com/angletonisd

Monthly DHMO Premiums Tier

Finding a network dentist is easy. Rate

Employee Only

$13.25

Employee + 1 Dependent

$24.43

Employee + Child(ren)

$24.43

Employee + 2 or More Dependents

$34.20

There are several ways to choose your network general dentist:  Find a dentist at Cigna.com. Our online dental directory is updated weekly.  Call 1.800.Cigna24 (1.800.244.6224) to speak with a customer service representative. Our representatives can send you a customized dental directory listing via email. 21

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

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.

DID YOU KNOW?

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

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

In-Network

Out-of-Network

Covered in full

Up to $42 retail

EE Only

$9.84

Covered in full $150 retail allowance

Up to $37 retail Up to $81 retail

EE + 1 dependent

$19.04

EE + Family

$27.96

Covered in full

Not Covered

$50 retail allowance

Not Covered

Exam

$10

See description3

Up to $61 retail

Materials₁

$25

Contact Lens Fitting (standard & specialty)

$25

Co-Pays

$150 retail allowance Up to $100 retail

Lenses (standard) per pair Single Vision Bifocal Trifocal

Monthly Premiums

Covered in full Covered in full Covered in full

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

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.

Services/Frequency Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

Materials co-pay applies to lenses and frames only, not contact lenses 2 The specialty contact lens fitting is for new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. 3 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 4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary. Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) lenses. 5Discounts

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

provider.

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal Scratch coat $13 $13 Ultraviolet coat $15 $15 Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50 Polycarbonate $40 20% off retail High index 1.6 $55 20% off retail Photochromics $80 20% off retail

Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

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.

DID YOU KNOW?

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.

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

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

   

Mental Illness, Alcoholism and Substance Abuse 



     

Social Security Disability Insurance (please see www.mybenefitshub.com/angletonisd for exceptions) Workers' Compensation Other employer-based Insurance coverage you may have Unemployment benefits Settlements or judgments for income loss Retirement benefits that your employer fully or partially pays for (such as a pension plan.)



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

Retirement benefits if you were already receiving them before you became disabled Retirement benefits that are funded by your after-tax contributions Your personal savings, investment, IRAs or Keoghs Profit-sharing Most personal disability policies Social Security increases

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

Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:  

War or act of war (declared or not) Military service for any country engaged in war or other armed conflict

You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

What other benefits are included in my disability coverage?

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

The commission of, or attempt to commit a felony An intentionally self-inflicted injury Any case where your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits

 

Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment. Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit. Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services. The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services. Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived. Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims. 25

Long Term Disability For the Premium benefit option â&#x20AC;&#x201C; the table below applies to disabilities resulting from injury or sickness: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

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 MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days

Annual Earnings

Monthly Earnings

Monthly Benefit

0/3

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600

$300

$200

$8.98

$7.00

$5.92

$3.84

$3.32

$2.48

$5,400

$450

$300

$13.47

$10.50

$8.88

$5.76

$4.98

$3.72

$7,200

$600

$400

$17.96

$14.00

$11.84

$7.68

$6.64

$4.96

$9,000

$750

$500

$22.45

$17.50

$14.80

$9.60

$8.30

$6.20

$10,800

$900

$600

$26.94

$21.00

$17.76

$11.52

$9.96

$7.44

$12,600

$1,050

$700

$31.43

$24.50

$20.72

$13.44

$11.62

$8.68

$14,400

$1,200

$800

$35.92

$28.00

$23.68

$15.36

$13.28

$9.92

$16,200

$1,350

$900

$40.41

$31.50

$26.64

$17.28

$14.94

$11.16

$18,000

$1,500

$1,000

$44.90

$35.00

$29.60

$19.20

$16.60

$12.40

$19,800

$1,650

$1,100

$49.39

$38.50

$32.56

$21.12

$18.26

$13.64

$21,600

$1,800

$1,200

$53.88

$42.00

$35.52

$23.04

$19.92

$14.88

$23,400

$1,950

$1,300

$58.37

$45.50

$38.48

$24.96

$21.58

$16.12

$25,200

$2,100

$1,400

$62.86

$49.00

$41.44

$26.88

$23.24

$17.36

$27,000

$2,250

$1,500

$67.35

$52.50

$44.40

$28.80

$24.90

$18.60

$28,800

$2,400

$1,600

$71.84

$56.00

$47.36

$30.72

$26.56

$19.84

$30,600

$2,550

$1,700

$76.33

$59.50

$50.32

$32.64

$28.22

$21.08

$32,400

$2,700

$1,800

$80.82

$63.00

$53.28

$34.56

$29.88

$22.32

$34,200

$2,850

$1,900

$85.31

$66.50

$56.24

$36.48

$31.54

$23.56

$36,000

$3,000

$2,000

$89.80

$70.00

$59.20

$38.40

$33.20

$24.80

$37,800

$3,150

$2,100

$94.29

$73.50

$62.16

$40.32

$34.86

$26.04

$39,600

$3,300

$2,200

$98.78

$77.00

$65.12

$42.24

$36.52

$27.28

$41,400

$3,450

$2,300

$103.27

$80.50

$68.08

$44.16

$38.18

$28.52

$43,200

$3,600

$2,400

$107.76

$84.00

$71.04

$46.08

$39.84

$29.76

$45,000

$3,750

$2,500

$112.25

$87.50

$74.00

$48.00

$41.50

$31.00

$46,800

$3,900

$2,600

$116.74

$91.00

$76.96

$49.92

$43.16

$32.24

$48,600

$4,050

$2,700

$121.23

$94.50

$79.92

$51.84

$44.82

$33.48

$50,400

$4,200

$2,800

$125.72

$98.00

$82.88

$53.76

$46.48

$34.72

$52,200

$4,350

$2,900

$130.21

$101.50

$85.84

$55.68

$48.14

$35.96

$54,000

$4,500

$3,000

$134.70

$105.00

$88.80

$57.60

$49.80

$37.20

$55,800

$4,650

$3,100

$139.19

$108.50

$91.76

$59.52

$51.46

$38.44

$57,600

$4,800

$3,200

$143.68

$112.00

$94.72

$61.44

$53.12

$39.68

$59,400

$4,950

$3,300

$148.17

$115.50

$97.68

$63.36

$54.78

$40.92

Long Term Disability MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/3

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$61,200

$5,100

$3,400

$152.66

$119.00

$100.64

$65.28

$56.44

$42.16

$63,000

$5,250

$3,500

$157.15

$122.50

$103.60

$67.20

$58.10

$43.40

$64,800

$5,400

$3,600

$161.64

$126.00

$106.56

$69.12

$59.76

$44.64

$66,600

$5,550

$3,700

$166.13

$129.50

$109.52

$71.04

$61.42

$45.88

$68,400

$5,700

$3,800

$170.62

$133.00

$112.48

$72.96

$63.08

$47.12

$70,200

$5,850

$3,900

$175.11

$136.50

$115.44

$74.88

$64.74

$48.36

$72,000

$6,000

$4,000

$179.60

$140.00

$118.40

$76.80

$66.40

$49.60

$73,800

$6,150

$4,100

$184.09

$143.50

$121.36

$78.72

$68.06

$50.84

$75,600

$6,300

$4,200

$188.58

$147.00

$124.32

$80.64

$69.72

$52.08

$77,400

$6,450

$4,300

$193.07

$150.50

$127.28

$82.56

$71.38

$53.32

$79,200

$6,600

$4,400

$197.56

$154.00

$130.24

$84.48

$73.04

$54.56

$81,000

$6,750

$4,500

$202.05

$157.50

$133.20

$86.40

$74.70

$55.80

$82,800

$6,900

$4,600

$206.54

$161.00

$136.16

$88.32

$76.36

$57.04

$84,600

$7,050

$4,700

$211.03

$164.50

$139.12

$90.24

$78.02

$58.28

$86,400

$7,200

$4,800

$215.52

$168.00

$142.08

$92.16

$79.68

$59.52

$88,200

$7,350

$4,900

$220.01

$171.50

$145.04

$94.08

$81.34

$60.76

$90,000

$7,500

$5,000

$224.50

$175.00

$148.00

$96.00

$83.00

$62.00

$91,800

$7,650

$5,100

$228.99

$178.50

$150.96

$97.92

$84.66

$63.24

$93,600

$7,800

$5,200

$233.48

$182.00

$153.92

$99.84

$86.32

$64.48

$95,400

$7,950

$5,300

$237.97

$185.50

$156.88

$101.76

$87.98

$65.72

$97,200

$8,100

$5,400

$242.46

$189.00

$159.84

$103.68

$89.64

$66.96

$99,000

$8,250

$5,500

$246.95

$192.50

$162.80

$105.60

$91.30

$68.20

$100,800

$8,400

$5,600

$251.44

$196.00

$165.76

$107.52

$92.96

$69.44

$102,600

$8,550

$5,700

$255.93

$199.50

$168.72

$109.44

$94.62

$70.68

$104,400

$8,700

$5,800

$260.42

$203.00

$171.68

$111.36

$96.28

$71.92

$106,200

$8,850

$5,900

$264.91

$206.50

$174.64

$113.28

$97.94

$73.16

$108,000

$9,000

$6,000

$269.40

$210.00

$177.60

$115.20

$99.60

$74.40

$109,800

$9,150

$6,100

$273.89

$213.50

$180.56

$117.12

$101.26

$75.64

$111,600

$9,300

$6,200

$278.38

$217.00

$183.52

$119.04

$102.92

$76.88

$113,400

$9,450

$6,300

$282.87

$220.50

$186.48

$120.96

$104.58

$78.12

$115,200

$9,600

$6,400

$287.36

$224.00

$189.44

$122.88

$106.24

$79.36

$117,000

$9,750

$6,500

$291.85

$227.50

$192.40

$124.80

$107.90

$80.60

$118,800

$9,900

$6,600

$296.34

$231.00

$195.36

$126.72

$109.56

$81.84

$120,600

$10,050

$6,700

$300.83

$234.50

$198.32

$128.64

$111.22

$83.08

$122,400

$10,200

$6,800

$305.32

$238.00

$201.28

$130.56

$112.88

$84.32

$124,200

$10,350

$6,900

$309.81

$241.50

$204.24

$132.48

$114.54

$85.56

$126,000

$10,500

$7,000

$314.30

$245.00

$207.20

$134.40

$116.20

$86.80

$127,800

$10,650

$7,100

$318.79

$248.50

$210.16

$136.32

$117.86

$88.04

$129,600

$10,800

$7,200

$323.28

$252.00

$213.12

$138.24

$119.52

$89.28

$131,400

$10,950

$7,300

$327.77

$255.50

$216.08

$140.16

$121.18

$90.52

$133,200

$11,100

$7,400

$332.26

$259.00

$219.04

$142.08

$122.84

$91.76

$135,000

$11,250

$7,500

$336.75

$262.50

$222.00

$144.00

$124.50

$93.00

$136,800

$11,400

$7,600

$341.24

$266.00

$224.96

$145.92

$126.16

$94.24

$138,600

$11,550

$7,700

$345.73

$269.50

$227.92

$147.84

$127.82

$95.48

$140,400

$11,700

$7,800

$350.22

$273.00

$230.88

$149.76

$129.48

$96.72

$142,200

$11,850

$7,900

$354.71

$276.50

$233.84

$151.68

$131.14

$97.96

$144,000

$12,000

$8,000

$359.20

$280.00

$236.80

$153.60

$132.80

$99.20

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS

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.

DID YOU KNOW? Breast Cancer is the most commonly diagnosed cancer in women.

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

(03/16)

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

Summary of Benefits

Plan 1

Plan 2

Cancer Treatment Policy Benefits

Level 3

Level 4

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

$15,000

$20,000

$50 per treatment

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

paid in same manner and under the same maximums as any other benefit Level 4

Hormone Therapy - Maximum of 12 treatments per calendar year Experimental Treatment Internal Cancer First Occurrence Rider Benefits Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Heart Attack/Stroke First Occurrence Rider Benefits

Level 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

$600 per day $300 per day

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

Total Monthly Premiums by Plan** Issue Ages 18 +

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$15.46

$24.80

$33.24

$53.70

$19.60

$30.40

$37.38

$59.34

**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.

APSB-22339(TX)-0615 MGM/FBS Angleton ISD

GC14 Limited Benefit Group Cancer Indemnity Insurance 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, the time limit on certain defenses and preexisting 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.

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.

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.

Heart Attack/Stroke First Occurrence Benefits Limitations and Exclusions

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; or 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).

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.

30 APSB-22339(TX)-0615 MGM/FBS Angleton ISD

GC14 Limited Benefit Group Cancer Indemnity Insurance Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any heart attack or stroke 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.

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 a covered person’s death or the date the lump sum benefit amount for heart attack or stroke 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, as defined in the policy.

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.

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 detailed 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 Cancer Indemnity Insurance | (10/14) | MGM/FBS | Angleton ISD

APSB-22339(TX)-0615 MGM/FBS Angleton ISD

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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.

DID YOU KNOW?

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

Critical Illness Plan Type

Portability

Critical Illness

Included

Coverage Amounts

Recurrence Benefit



Included – 25% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke.

 

Employee - $5,000 to $30,000 in increments of $5,000 Spouse - $5,000 to $15,000 in increments of $5,000 Child – 25% of Employee Coverage Amount

Guarantee Issue  

Premium Paid by the Employee

Employee – $30,000 Spouse - $15,000

Pre-Existing Condition Employee 12/12 exclusion

Monthly Rates per $1,000 Issue Ages

Non-Tobacco

Tobacco

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

.29 .31 .45 .62 .90 1.20 1.56 2.02 2.59 2.97 5.55

This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. 33

AUL A ONEAMERICA COMPANY YOUR BENEFITS PACKAGE

Life and AD&D

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.

DID YOU KNOW? Motor vehicle crashes are the

cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.

Life and AD&D Group Term Life including matching AD&D Coverage    

Life and AD&D insurance coverage amount of $10,000 at no cost to you Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns

AUL's Group Voluntary Term Life Insurance Terms and Definitions Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 30 hours per week.

Continuation of Coverage Options: Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70.

OR Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.

Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

Waiver of Premium:

If approved, this benefit waives your and your dependents' insurance premium in case you become totally disabled and are Since everyone's needs are different, this plan offers flexibility for unable to collect a paycheck. you to choose a benefit amount that fits your needs and budget. Reductions: Upon reaching certain ages, your original benefit amount will Guaranteed Issue Amounts: reduce to a percentage as shown in the following schedule. This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage Age: 65 70 now and decide to enroll later, you will need to provide Evidence of Insurability. Reduces To: 65% 50%

Flexible Choices:

Employee Guaranteed Issue Amount

$200,000

Spouse Guaranteed Issue Amount

$50,000

Timely Enrollment: Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

Evidence of Insurability: If you elect a benefit amount over the Guaranteed Issue Amount shown above for you or your eligible dependents, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you and/or your dependents will be approved or declined for insurance coverage by AUL.

Life Event Benefit: You may be able to add coverage or increase your benefit amount if you apply within 31 days from the date of a life event. Examples of a life event include marriage, the birth of a child, or adoption.

Life and AD&D Group Term Life including matching AD&D Coverage   

Angleton ISD provides a $10,000 Basic Life Policy at no cost to you. Waiver of premium benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns

Monthly Payroll Deduction Illustration About your benefit options:    

You may select a minimum Life benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000. Life amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. Employee must select coverage to select any Dependent coverage. Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life Options $10,000

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$.40

$.60

$1.00

$1.20

$1.80

$3.30

$6.10

$9.40

$18.40

$32.90

$20,000

$.80

$1.20

$2.00

$2.40

$3.60

$6.60

$12.20

$18.80

$36.80

$65.80

$30,000

$1.20

$1.80

$3.00

$3.60

$5.40

$9.90

$18.30

$28.20

$55.20

$98.70

$40,000

$1.60

$2.40

$4.00

$4.80

$7.20

$13.20

$24.40

$37.60

$73.60 $131.60

$50,000

$2.00

$3.00

$5.00

$6.00

$9.00

$16.50

$30.50

$47.00

$92.00 $164.50

$100,000

$4.00

$6.00

$10.00 $12.00

$18.00

$33.00

$61.00

$94.00 $184.00 $329.00

$120,000

$4.80

$7.20

$12.00 $14.40

$21.60

$39.60

$73.20 $112.80 $220.80 $394.80

$160,000

$6.40

$9.60

$16.00 $19.20

$28.80

$52.80

$97.60 $150.40 $294.40 $526.40

$180,000

$7.20

$10.80 $18.00 $21.60

$32.40

$59.40 $109.80 $169.20 $331.20 $592.20

$200,000

$8.00

$12.00 $20.00 $24.00

$36.00

$66.00 $122.00 $188.00 $368.00 $658.00

SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01) Life Options $10,000

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$.40

$.60

$1.00

$1.20

$1.80

$3.30

$6.10

$9.40

$18.40

$32.90

$20,000

$.80

$1.20

$2.00

$2.40

$3.60

$6.60

$12.20

$18.80

$36.80

$65.80

$30,000

$1.20

$1.80

$3.00

$3.60

$5.40

$9.90

$18.30

$28.20

$55.20

$98.70

$40,000

$1.60

$2.40

$4.00

$4.80

$7.20

$13.20

$24.40

$37.60

$73.60 $131.60

$50,000

$2.00

$3.00

$5.00

$6.00

$9.00

$16.50

$30.50

$47.00

$92.00 $164.50

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Option 1:

Child(ren) 6 months to age 26 $10,000

Child(ren) live birth to 6 months $1,000

Monthly Payroll Deduction Life Amount $1.36

Life and AD&D Monthly Payroll Deduction Illustration: Premium Policy to Maximum About your benefit options:  

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000. Amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$0.40

$0.60

$1.00

$1.20

$1.80

$3.30

$6.10

$9.40

$18.40

$32.90

$20,000

$0.80

$1.20

$2.00

$2.40

$3.60

$6.60

$12.20

$18.80

$36.80

$65.80

$30,000

$1.20

$1.80

$3.00

$3.60

$5.40

$9.90

$18.30

$28.20

$55.20

$98.70

$40,000

$1.60

$2.40

$4.00

$4.80

$7.20

$13.20

$24.40

$37.60

$73.60 $131.60

$50,000

$2.00

$3.00

$5.00

$6.00

$9.00

$16.50

$30.50

$47.00

$92.00 $164.50

$60,000

$2.40

$3.60

$6.00

$7.20

$10.80

$19.80

$36.60

$56.40 $110.40 $197.40

$70,000

$2.80

$4.20

$7.00

$8.40

$12.60

$23.10

$42.70

$65.80 $128.80 $230.30

$80,000

$3.20

$4.80

$8.00

$9.60

$14.40

$26.40

$48.80

$75.20 $147.20 $263.20

$90,000

$3.60

$5.40

$9.00

$10.80

$16.20

$29.70

$54.90

$84.60 $165.60 $296.10

$100,000

$4.00

$6.00

$10.00 $12.00

$18.00

$33.00

$61.00

$94.00 $184.00 $329.00

$110,000

$4.40

$6.60

$11.00 $13.20

$19.80

$36.30

$67.10 $103.40 $202.40 $361.90

$120,000

$4.80

$7.20

$12.00 $14.40

$21.60

$39.60

$73.20 $112.80 $220.80 $394.80

$130,000

$5.20

$7.80

$13.00 $15.60

$23.40

$42.90

$79.30 $122.20 $239.20 $427.70

$140,000

$5.60

$8.40

$14.00 $16.80

$25.20

$46.20

$85.40 $131.60 $257.60 $460.60

$150,000

$6.00

$9.00

$15.00 $18.00

$27.00

$49.50

$91.50 $141.00 $276.00 $493.50

$160,000

$6.40

$9.60

$16.00 $19.20

$28.80

$52.80

$97.60 $150.40 $294.40 $526.40

$170,000

$6.80

$10.20 $17.00 $20.40

$30.60

$56.10 $103.70 $159.80 $312.80 $559.30

$180,000

$7.20

$10.80 $18.00 $21.60

$32.40

$59.40 $109.80 $169.20 $331.20 $592.20

$190,000

$7.60

$11.40 $19.00 $22.80

$34.20

$62.70 $115.90 $178.60 $349.60 $625.10

$200,000

$8.00

$12.00 $20.00 $24.00

$36.00

$66.00 $122.00 $188.00 $368.00 $658.00

Life and AD&D Monthly Payroll Deduction Illustration: Premium Policy to Maximum (cntd.) EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life Options

0-19

20-24

25-29

$210,000 $220,000 $230,000 $240,000 $250,000 $260,000 $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 $390,000 $400,000 $410,000 $420,000 $430,000 $440,000 $450,000 $460,000 $470,000 $480,000 $490,000 $500,000

$8.40 $8.80 $9.20 $9.60 $10.00 $10.40 $10.80 $11.20 $11.60 $12.00 $12.40 $12.80 $13.20 $13.60 $14.00 $14.40 $14.80 $15.20 $15.60 $16.00 $16.40 $16.80 $17.20 $17.60 $18.00 $18.40 $18.80 $19.20 $19.60 $20.00

30-34

35-39

40-44

45-49

50-54

55-59

60-64

The amounts below require Statement of Insurability form $8.40 $12.60 $21.00 $25.20 $37.80 $69.30 $128.10 $8.80 $13.20 $22.00 $26.40 $39.60 $72.60 $134.20 $9.20 $13.80 $23.00 $27.60 $41.40 $75.90 $140.30 $9.60 $14.40 $24.00 $28.80 $43.20 $79.20 $146.40 $10.00 $15.00 $25.00 $30.00 $45.00 $82.50 $152.50 $10.40 $15.60 $26.00 $31.20 $46.80 $85.80 $158.60 $10.80 $16.20 $27.00 $32.40 $48.60 $89.10 $164.70 $11.20 $16.80 $28.00 $33.60 $50.40 $92.40 $170.80 $11.60 $17.40 $29.00 $34.80 $52.20 $95.70 $176.90 $12.00 $18.00 $30.00 $36.00 $54.00 $99.00 $183.00 $12.40 $18.60 $31.00 $37.20 $55.80 $102.30 $189.10 $12.80 $19.20 $32.00 $38.40 $57.60 $105.60 $195.20 $13.20 $19.80 $33.00 $39.60 $59.40 $108.90 $201.30 $13.60 $20.40 $34.00 $40.80 $61.20 $112.20 $207.40 $14.00 $21.00 $35.00 $42.00 $63.00 $115.50 $213.50 $14.40 $21.60 $36.00 $43.20 $64.80 $118.80 $219.60 $14.80 $22.20 $37.00 $44.40 $66.60 $122.10 $225.70 $15.20 $22.80 $38.00 $45.60 $68.40 $125.40 $231.80 $15.60 $23.40 $39.00 $46.80 $70.20 $128.70 $237.90 $16.00 $24.00 $40.00 $48.00 $72.00 $132.00 $244.00 $16.40 $24.60 $41.00 $49.20 $73.80 $135.30 $250.10 $16.80 $25.20 $42.00 $50.40 $75.60 $138.60 $256.20 $17.20 $25.80 $43.00 $51.60 $77.40 $141.90 $262.30 $17.60 $26.40 $44.00 $52.80 $79.20 $145.20 $268.40 $18.00 $27.00 $45.00 $54.00 $81.00 $148.50 $274.50 $18.40 $27.60 $46.00 $55.20 $82.80 $151.80 $280.60 $18.80 $28.20 $47.00 $56.40 $84.60 $155.10 $286.70 $19.20 $28.80 $48.00 $57.60 $86.40 $158.40 $292.80 $19.60 $29.40 $49.00 $58.80 $88.20 $161.70 $298.90 $20.00 $30.00 $50.00 $60.00 $90.00 $165.00 $305.00

65-69

70-74

75+

$197.40 $206.80 $216.20 $225.60 $235.00 $244.40 $253.80 $263.20 $272.60 $282.00 $291.40 $300.80 $310.20 $319.60 $329.00 $338.40 $347.80 $357.20 $366.60 $376.00 $385.40 $394.80 $404.20 $413.60 $423.00 $432.40 $441.80 $451.20 $460.60 $470.00

$386.40 $404.80 $423.20 $441.60 $460.00 $478.40 $496.80 $515.20 $533.60 $552.00 $570.40 $588.80 $607.20 $625.60 $644.00 $662.40 $680.80 $699.20 $717.60 $736.00 $754.40 $772.80 $791.20 $809.60 $828.00 $846.40 $864.80 $883.20 $901.60 $920.00

$690.90 $723.80 $756.70 $789.60 $822.50 $855.40 $888.30 $921.20 $954.10 $987.00 $1,019.90 $1,052.80 $1,085.70 $1,118.60 $1,151.50 $1,184.40 $1,217.30 $1,250.20 $1,283.10 $1,316.00 $1,348.90 $1,381.80 $1,414.70 $1,447.60 $1,480.50 $1,513.40 $1,546.30 $1,579.20 $1,612.10 $1,645.00

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Option 1:

Child(ren) 6 months to age 26 $10,000

Child(ren) live birth to 6 months $1,000

Monthly Payroll Deduction Life Amount $1.36

Life and AD&D Monthly Payroll Deduction Illustration: Premium Policy to Maximum About your benefit options:   

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000. Employee must select coverage to select any Dependent coverage. The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.

EMPLOYEE ONLY AD&D

FAMILY AD&D

Monthly Deduction

Employee Volume

Spouse Volume

Child Volume

Monthly Reduction

$10,000

$0.200

$10,000

$5,000

$1,000

$0.500

$20,000

$0.400

$20,000

$10,000

$2,000

$1.000

$30,000

$0.600

$30,000

$15,000

$3,000

$1.500

$40,000

$0.800

$40,000

$20,000

$4,000

$2.000

$50,000

$1.000

$50,000

$25,000

$5,000

$2.500

$60,000

$1.200

$60,000

$30,000

$6,000

$3.000

$70,000

$1.400

$70,000

$35,000

$7,000

$3.500

$80,000

$1.600

$80,000

$40,000

$8,000

$4.000

$90,000

$1.800

$90,000

$45,000

$9,000

$4.500

$100,000

$2.000

$100,000

$50,000

$10,000

$5.000

$150,000

$3.000

$150,000

$75,000

$15,000

$7.500

$200,000

$4.000

$200,000

$100,000

$20,000

$10.000

$250,000

$5.000

$250,000

$125,000

$25,000

$12.500

$300,000

$6.000

$300,000

$150,000

$30,000

$15.000

$350,000

$7.000

$350,000

$175,000

$35,000

$17.500

$400,000

$8.000

$400,000

$200,000

$40,000

$20.000

$450,000

$9.000

$450,000

$225,000

$45,000

$22.500

$500,000

$10.000

$500,000

$250,000

$50,000

$25.000

Volume

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance Company® (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change. This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued. 39

ONE AMERICA

EAP (Employee Assistance Program)

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

38%

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

ComPsych GuidanceResources® Program Confidential Counseling This no-cost counseling service helps you address stress, relationship 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 issue per year) and other resources for: › Stress, anxiety and depression › Job pressures › Relationship/marital conflicts › Grief and loss › Problems with children › Substance abuse

Financial Information and Resources Speak by phone with our Certified Public Accountants and Certified Financial Planners on a wide range of financial issues including: › Getting out of debt › Retirement planning › Credit card or loan problems › Estate planning › Tax questions › Saving for college

self-assessments › “Ask the Expert” personal responses to your questions › Child care, elder care, attorney and financial planner searches

Free Online Will Preparation 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 instructions for executing 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 instructions

Legal Support and Resources Talk to our attorneys by phone. If you require representation, we’ll refer you to a qualified attorney in your area for a free 30minute consultation with a 25% reduction in customary legal fees thereafter. Call about: › Divorce and family law › Real estate transactions › Debt and bankruptcy › Civil and criminal actions › Landlord/tenant issues › Contracts

Work-Life Solutions 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 relocation › Pet care › Making major purchases › Home repair

GuidanceResources® Online GuidanceResources Online is your one stop for expert information on the issues that matter most to you...relationships, work, school, children, wellness, legal, financial, free time and more. › Timely articles, HelpSheetsSM , tutorials, streaming videos and

OneAmerica is the marketing name for American United Life Insurance Company(R) (AUL). AUL markets ComPsych services. ComPsych Corporation is not an affiliate of AUL and is not a OneAmerica company. 41

5STAR

Individual Life

YOUR BENEFITS PACKAGE

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

DID YOU KNOW? Experts recommend at least

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

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

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

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

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

gourmet coffee OR per day to enrich your employee benefits package

It’s less expensive than you think.

Family Protection - Individual policies can be purchased on the employee, their spouse, children and grandchildren (ages 15 days to age 24). Quality of Life Benefit - Following a diagnosis of either a chronic illness or cognitive impairment, this rider accelerates a portion of the death benefit on a monthly basis – 4%; up to 75% of your benefit, and payable directly to you on a tax favored basis for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or  Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision. Convenience - Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On - Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the twoyear contestability period and/or under investigation. This product also contains no war or terrorism exclusions. * Life * Life insurance product underwritten by 5Star Life insurance Company (a Baton Rouge, Louisiana company) with an administrative office at 909 N. Washington Street, Alexandria, VA 22314

Family Protection Plan - Terminal Illness Monthly Rates with Quality of Life Rider Defined Benefit Age on App. Date $10,000

Employee Coverage Amounts $25,000

$50,000

$75,000

Spouse Coverage Amounts

$100,000 $125,000 $150,000

$10,000

$20,000

$30,000

18-25

$7.56

$12.40

$20.46

$28.52

$36.58

$44.65

$52.71

$7.56

$10.78

$14.01

$7.58

$12.46

$20.58

$28.71

$36.83

$44.96

$53.08

$7.58

$10.83

$14.08

$7.65

$12.63

$20.92

$29.21

$37.50

$45.79

$54.08

$7.65

$10.97

$14.28

$7.74

$12.85

$21.38

$29.90

$38.42

$46.94

$55.46

$7.74

$11.15

$14.56

$7.88

$13.21

$22.08

$30.96

$39.83

$48.71

$57.58

$7.88

$11.43

$14.98

$8.07

$13.67

$23.00

$32.33

$41.67

$51.00

$60.33

$8.07

$11.80

$15.53

$8.27

$14.17

$24.00

$33.83

$43.67

$53.50

$63.33

$8.27

$12.20

$16.13

$8.49

$14.73

$25.13

$35.52

$45.92

$56.31

$66.71

$8.49

$12.65

$16.81

$8.73

$15.31

$26.29

$37.27

$48.25

$59.23

$70.21

$8.73

$13.12

$17.51

$9.00

$16.00

$27.67

$39.33

$51.00

$62.67

$74.33

$9.00

$13.67

$18.33

$9.30

$16.75

$29.17

$41.58

$54.00

$66.42

$78.83

$9.30

$14.27

$19.23

$9.64

$17.60

$30.88

$44.15

$57.42

$70.69

$83.96

$9.64

$14.95

$20.26

$10.02

$18.54

$32.75

$46.96

$61.17

$75.38

$89.58

$10.02

$15.70

$21.38

$10.41

$19.52

$34.71

$49.90

$65.08

$80.27

$95.46

$10.41

$16.48

$22.56

$10.84

$20.60

$36.88

$53.15

$69.42

$85.69

$101.96

$10.84

$17.35

$23.86

$11.31

$21.77

$39.21

$56.65

$74.08

$91.52

$108.96

$11.31

$18.28

$25.26

$11.83

$23.08

$41.83

$60.58

$79.33

$98.08

$116.83

$11.83

$19.33

$26.83

$12.41

$24.52

$44.71

$64.90

$85.08

$105.27

$125.46

$12.41

$20.48

$28.56

$13.00

$26.00

$47.67

$69.33

$91.00

$112.67

$134.33

$13.00

$21.67

$30.33

$13.63

$27.56

$50.79

$74.02

$97.25

$120.48

$143.71

$13.63

$22.92

$32.21

$14.28

$29.19

$54.04

$78.90

$103.75

$128.60

$153.46

$14.28

$24.22

$34.16

$14.97

$30.92

$57.50

$84.08

$110.67

$137.25

$163.83

$14.97

$25.60

$36.23

$15.69

$32.73

$61.13

$89.52

$117.92

$146.31

$174.71

$15.69

$27.05

$38.41

$16.43

$34.56

$64.79

$95.02

$125.25

$155.48

$185.71

$16.43

$28.52

$40.61

$17.22

$36.54

$68.75

$100.96

$133.17

$165.38

$197.58

$17.22

$30.10

$42.98

$18.08

$38.69

$73.04

$107.40

$141.75

$176.10

$210.46

$18.08

$31.82

$45.56

$19.04

$41.10

$77.88

$114.65

$151.42

$188.19

$224.96

$19.04

$33.75

$48.46

$20.16

$43.90

$83.46

$123.02

$162.58

$202.15

$241.71

$20.16

$35.98

$51.81

$21.40

$47.00

$89.67

$132.33

$175.00

$217.67

$260.33

$21.40

$38.47

$55.53

$22.79

$50.48

$96.63

$142.77

$188.92

$235.06

$281.21

$22.79

$41.25

$59.71

$24.27

$54.17

$104.00

$153.83

$203.67

$253.50

$303.33

$24.27

$44.20

$64.13

$25.93

$58.33

$112.33

$166.33

$220.33

$274.33

$328.33

$25.93

$47.53

$69.13

$27.66

$62.65

$120.96

$179.27

$237.58

$295.90

$354.21

$27.66

$50.98

$74.31

$29.42

$67.04

$129.75

$192.46

$255.17

$317.88

$380.58

$29.42

$54.50

$79.58

$31.23

$71.56

$138.79

$206.02

$273.25

$340.48

$407.71

$31.23

$58.12

$85.01

Family Protection Plan - Terminal Illness Age on App. Date $10,000

Employee Coverage Amounts $25,000

$50,000

$75,000

Spouse Coverage Amounts

$100,000 $125,000 $150,000

$10,000

$20,000

$30,000

18-25

$7.56

$12.40

$20.46

$28.52

$36.58

$44.65

$52.71

$7.56

$10.78

$14.01

$33.12

$76.29

$148.25

$220.21

$292.17

$364.13

$436.08

$33.12

$61.90

$90.68

$35.08

$81.19

$158.04

$234.90

$311.75

$388.60

$465.46

$35.08

$65.82

$96.56

$37.13

$86.31

$168.29

$250.27

$332.25

$414.23

$496.21

$37.13

$69.92

$102.71

$39.31

$91.77

$179.21

$266.65

$354.08

$441.52

$528.96

$39.31

$74.28

$109.26

$41.68

$97.71

$191.08

$284.46

$377.83

$471.21

$564.58

$41.68

$79.03

$116.38

$44.33

$104.33

$204.33

$304.33

$404.33

$504.33

$604.33

$44.33

$84.33

$124.33

66*

$44.93

$105.81

$207.29

$308.77

$410.25

$511.73

$613.21

$44.93

$85.52

$126.11

67*

$48.25

$114.13

$223.92

$333.71

$443.50

$553.29

$663.08

$48.25

$92.17

$136.08

68*

$52.03

$123.58

$242.83

$362.08

$481.33

$600.58

$719.83

$52.03

$99.73

$147.43

69*

$56.33

$134.31

$264.29

$394.27

$524.25

$654.23

$784.21

$56.33

$108.32

$160.31

70*

$61.17

$146.42

$288.50

$430.58

$572.67

$714.75

$856.83

$61.17

$118.00

$174.83

*Quality of Life not available ages 66 - 70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 15 days to age 24). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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 TOâ&#x20AC;Ś PG. 11 FOR HSA VS. FSA COMPARISON

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

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

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB mid-September. Don’t forget, Flex Cards Are Good For 3 Years! For a list of sample expenses, please refer to the Angleton ISD benefit website: www.mybenefitshub.com/angletonisd

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

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

FSA Annual Contribution Max:

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

$2,550

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 claim FAQs

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/angletonisd

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

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

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

Get Your Money 1. 2. 3. 4.

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

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

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

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

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

About this Benefit Telehealth provides 24/7/365 access to boardcertified doctors via telephone consultations that can diagnose, recommend treatment and prescribe medication. Whether you are at home, traveling or at work, Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.

DID YOU KNOW?

75%

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

Telehealth When should I use MDLIVE?

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

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

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

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

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

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

How much does it cost? $10 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

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

Scan with your smartphone to get the app.

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

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

LEGAL SHIELD

Identity Theft

YOUR BENEFITS PACKAGE

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

DID YOU KNOW?

An identity is stolen every

2 seconds, and takes over

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

Identity Theft LegalShield® | IDShield® What is LegalShield? LegalShield was founded in 1972, with the mission to make equal justice under law a reality for all North Americans. The 3.5 million individuals enrolled as LegalShield members throughout the United States and Canada can talk to a lawyer on any personal legal matter, no matter how trivial or traumatic, all without worrying about high hourly costs. LegalShield has provided identity theft protection since 2003 with Kroll Advisory Solutions, the world’s leading company in ID Theft consulting and restoration. We have safeguarded over 1 million members, provided more than 200,000 identity consultations, and helped restore nearly 10,000 individual identities.

The LegalShield® Membership Includes:     

     

Personal Legal advice on unlimited issues Letters/calls made on your behalf Contract & documents reviewed (up to 15 pages) Residential Loan Document Assistance Lawyers prepare your Will, your Living Will and your Health Care Power of Attorney Moving Traffic Violations (available 15 days after enrollment) IRS Audit Assistance Trial Defense (if named defendant/respondent in a covered civil action suit) Uncontested Divorce, Separation, Adoption and/or Name Change Representation (available 90 days after enrollment) 25% Preferred Member Discount (Bankruptcy, Criminal Charges, DUI, Other Matters, etc.) 24/7 Emergency Access for covered situations

LegalShield legal plans cover the member; member’s spouse; never married dependent children under 26 living at home; dependent children under the age of 18 for whom the member is legal guardian; never married, dependent children up to age 26 if a full-time college student; and physically or mentally disabled dependent children. An individual rate is available for those enrollees who are not married, do not have a domestic partner and do not have minor children or dependents. No family benefits are available to individual plan members. Ask your Independent Associate for details.

Plan Effective Date: 9/1/2016 Payroll Deduction

Individual

Family

LegalShield

$14.95

$15.95

IDShield

$8.45

$16.95

Combined

$23.40

$28.90

(Monthly)

The IDShieldSM Privacy Monitoring Monitor your name, SNN, date of birth, email address (up to 10), phone numbers (up to 10), driver license & passport numbers, and medical ID numbers (up to 10), provides you with comprehensive identity protection service that leaves nothing to chance. Security Monitoring SNN, credit cards (up to 10), and bank account (up to 10) monitoring, sex offender search, financial activity alerts and quarterly credit score tracking keep you secure from every angle. With the family plan, Minor Identity Protection is included and provides monitoring for up to 8 children under the age of 18. Consultation Your identity protection plan includes 24/7/365 live support for covered emergencies, unlimited counseling, identity alerts, data breach notifications and lost wallet protection. Full Service Restoration Complete identity recovery services by Kroll Licensed Private Investigators and our $5 million service guarantee ensure that if your identity is stolen, it will be restored to its pre-theft status. IDShield plans are available at individual or family rates. A family rate covers the member, member’s spouse and up to 8 dependents up to the age of 18.

This is a general overview and is for illustrative purposes only. Plans and services vary from state to state. See a plan contract for your state of residence for complete terms, coverage, amounts, conditions and exclusions.

NOTES