2016 Benefit Guide Birdville ISD by Higginbotham Public Sector

BIRDVILLE ISD

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

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare and Scott & White HMO APL MEDlink® Medical Supplement Telehealth MDLIVE Delta Dental DPO & DHMO Superior Vision Cigna Disability APL Cancer AUl a OneAmerica Company Life and AD&D ID Watchdog ID Theft Protection MetLaw Legal Services Ceridian/LifeWorks Employee Assistance Program NBS Flexible Spending Account NBS Health Savings Account 2

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

FLIP TO... PG. 4 HOW TO ENROLL

11 12-15 16-19 20-21 22-25 26-27 28-31 32-35 36-37 38-39 40-41 42-43 44-47 48-49

PG. 6 BENEFIT UPDATES: WHAT’S NEW

PG. 12 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information BIRDVILLE ISD BENEFIT ADMINISTRATORS

DENTAL

EMPLOYER ASSISTANCE PROGRAM

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

Delta Dental (800) 521-2651 www.deltadentalins.com

Ceridian/LifeWorks (888) 456-1324 www.lifeworks.com

BIRDVILLE ISD BENEFITS OFFICE

VISION

IDENTITY THEFT

Birdville ISD Benefits Office (817) 547-5782 www.schools.birdvilleschools.net/benefits

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

ID Watchdog (800) 774-3772 www.idwatchdog.com

TRS ACTIVECARE MEDICAL

DISABILITY

HYATT METLAW

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

Cigna (800) 362-4462 www.mycigna.com

MetLife (800) 821-6400 www.metlife.com

TRS HMO MEDICAL

CANCER

FLEXIBLE SPENDING ACCOUNT

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

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

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

MEDICAL SUPPLEMENT—MEDLINK ®

LIFE AND AD&D

HEALTH SAVINGS ACCOUNT (HSA)

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

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

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

TELEHEALTH

403(B) /457 PLANS

MDLIVE (866) 365-1663 www.consultmdlive.com

JEM (800) 943-9179 www.jemtpa.com ISC GROUP, Inc. (800) 888-3520 www.iscgroup.com/home

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

TEXT

need to complete your enrollment.

“birdvilleisd”

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 the Birdville ISD benefits

Our online benefit enrollment

website from your computer, tablet

platform provides a simple and

or smartphone!

easy to navigate process. Enroll at your own pace, whether at home or at work. www.mybenefitshub.com/ birdvilleisd 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/birdvilleisd

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

Username:

G O

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

birdvilleisd. Click on the benefit plan you need information on

notify your employer of any discrepancy in personal and/or

benefit information.



For benefit summaries and claim forms, go to your school

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

(i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and

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

timeframe will result in the forfeiture of coverage.

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

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

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.

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 Birdville 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

To age 26

Telehealth

MDLIVE

To age 26

Dental High, Low & DHMO

Delta Dental

To age 26

Vision

Superior Vision

To age 26

MEDlink®

American Public Life

To age 26

Cancer

American Public Life

To age 26

Voluntary Life & AD&D

OneAmerica

To age 26

ID Theft Protection

ID Watchdog

To age 26

MetLaw

MetLife

To age 26

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

Annual Benefit Enrollment YOU MUST RE-ELECT OR DECLINE YOUR MEDICAL PLAN Annual Benefit Enrollment has been set for July and August by TRS. For additional Benefit Information: View the Benefits Open Enrollment power point. BISD home page- Departments-Benefits- 2016-2017 Benefits Enrollment.

Benefit Updates - What’s New: NEW: Long-Term Disability insurance by Cigna - Your current Disability plan will automatically change Cigna’s equivalent. You may change your election during open enrollment.

Don’t Forget! Social Security Numbers for your dependents are required regardless if they are enrolled in coverage or not. Please make sure you have these items on hand when going through your open enrollment. Due to the Affordable Care Act (ACA), every employee is required to login and complete the enrollment process, even if you are declining benefits Login and complete your benefit enrollment from: 7/18/2016-8/22/2016.

Important Enrollment assistance is available by calling Financial Benefit Services at (469) 385-4685 to speak to a representative. Spanish speaking representatives are also available. Annual Open Enrollment 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 30 days of event). 8

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2016 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 tax-free.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible

Maximum Contribution

$1,300 single (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. 48

FLIP TO… PG. 44

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-aand-b-recommendations

Plan pays 100% (deductible waived)

Some examples of preventive care frequency and services:  Routine physicals – annually Immunizations recommended by the Advisory Committee on age 12 and over Immunization Practices of the Centers for Disease Control and  Well-child care – unlimited Prevention (CDC) with respect to the individual involved. up to age 12 Evidence−informed preventive care and screenings provided  Well woman exam & pap for in the comprehensive guidelines supported by the Health smear – annually age 18 and Resources and Services Administration (HRSA) for infants, over children and adolescents. Additional preventive care and  Mammograms – 1 every year screenings for women, not described above, as provided for in age 35 and over comprehensive guidelines supported by the HRSA  Colonoscopy – 1 every 10 www.hhs.gov/healthcare/facts-and-features/fact-sheets/ years age 50 and over preventive-services-covered-under-aca/#CoveredPreventive  Prostate cancer screening – 1 ServicesforAdults per year age 50 and over  Smoking cessation For purposes of this benefit, the current recommendations of counseling – 8 visits per 12 the USPSTF regarding breast cancer screening and months mammography and prevention will be considered the most  Healthy diet/obesity current (other than those issued in or around November counseling – unlimited to age 2009). 22; age 22 and over-26 visits The preventive care services described above may change as per 12 months USPSTF, CDC and HRSA guidelines are modified.  Breastfeeding support – 6 lactation counseling visits per (Examples of covered services included are: 12 months 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.

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

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

After deductible, plan pays 80%; $60 copay for specialist participant pays 20%

$50 copay for specialist

Annual Hearing Examination Participant pays

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

$30 copay for primary $50 copay for specialist

$30 copay for primary $60 copay for specialist

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.

2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services Preventive Services

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions

Copay

Annual Deductible

$1,000 Individual/ $3,000 Family

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

Lifetime Paid Benefit Maximum

Outpatient Services

$5,000 Individual/ $10,000 Family (includes combined Medical and RX copays, deductibles and coinsurance)

None

Copay $20 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections

No Charge 20% after deductible

Outpatient Surgery

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

Maternity Care

Copay

Prenatal Care

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

Inpatient Delivery

Inpatient Services

Copay

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

Diagnostic & Therapeutic Services Physical and Speech Therapy 5

Manipulative Therapy

Equipment and Supplies

$150 per day4 and 20% of charges after deductible

Copay $50 copay 20% without office visit $40 plus 20% with office visit

Copay

Preferred Diabetic Supplies and Equipment

$3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment

30% after Rx deductible

Durable Medical Equipment/ Prosthetics

Copay

20% after deductible

2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services

Copay

Home Health Care Visit

$50 co-pay

Worldwide Emergency Care

Copay

Nurse Advice Line

1-877-505-7947

Online Services

No Charge â&#x20AC;&#x201D; go to www.trs.swhp.org

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$100

Does not apply to preferred generic drugs

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

Maintenance Quantity

Retail Quantity (Up to a 30-day supply)

BSWH Pharmacies Only (Up to a 90-day supply)

$3 copay

$6 copay

Preferred Brand

30% after Rx deductible

Non-preferred

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after deductible

Not available

Preferred Generic7

Mail Order

Specialty Medications (Up to a 30-day supply)

1-800-707-3477

Copay 20% after Rx deductible

Including all services billed with office visit Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after deductible 5 5 visits max per month, 35 max visit per year 6 Copay waived if admitted within 24 hours 7 If a brand name drug is dispensed when a generic is available, 50% copay applies 2

AMERICAN PUBLIC LIFE YOUR BENEFITS

MEDlinkÂŽIV

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

DID YOU KNOW?

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

(03/16) 16

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 Birdville ISD Benefits Website: www.mybenefitshub.com/birdvilleisd

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Birdville 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 NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 1

Maximum In-Hospital Benefits

$2,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible

$0 per Covered Person per Confinement

Outpatient Benefit Rider Maximum Outpatient Benefits

$500 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible

$0 per Covered Person Per Occurrence

Covered Outpatient Services Hospital Emergency Room

Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility

Maximum of three Urgent Care visits per Covered Person per Calendar Year. Maximum of six Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Surgery

Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Diagnostic Testing

Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Total Monthly Premiums by Plan* Employee

Employee & Spouse

Employee & Child

Employee & Family

Ages 18-54

$30.68

$70.55

$52.15

$92.03

Ages 55+

$46.01

$105.83

$78.22

$138.04

*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.

Important Policy Provisions Eligibility

You are eligible to be covered under this Policy/Certificate if you are Actively At Work, qualify for coverage as defined in the Master Application, are covered under your Employer’s Medical Plan and are under age 70 (if you work for an employer employing less than 20 employees). Your Eligible Dependents, as defined in the Policy/Certificate, are eligible for coverage if they are covered under the Employer’s Medical Plan. You must apply for insurance during the Initial Enrollment period or on the date the person first becomes eligible for coverage. If you do not apply during the Initial Enrollment period or on the date you become eligible for coverage, you may be subject to additional underwriting by APL. Evidence of coverage under your Employer’s Medical Plan is required.

APSB-22354(TX) MGM/FBS Birdville ISD

When Coverage Begins

Coverage will begin on the requested Certificate Effective Date or the Certificate Effective Date assigned by us, upon approval of your application, if our underwriting rules are met, the premium has been paid and all persons to be insured are covered under your Employer’s Medical Plan and you are Actively At Work on the Certificate Effective Date. If you are not Actively At Work on the Certificate Effective Date due to disability, Injury, Sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to Actively At Work.

Limitations & Exclusions No benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of the Insured’s Employer’s Medical Plan provision, described in the Policy. A hospital is not an institution, or part thereof, used as: a place for rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Pre-Existing Condition Limitation

No benefits are payable during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date for any loss resulting from a Pre-Existing Condition. The Pre-Existing Condition Limitation will apply only if the Covered Person is subject to a Pre-Existing Condition Limitation under the Employer’s Medical Plan. Therefore, any Pre-Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan.

Exclusions

No benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request) s an intentionally self-inflicted Injury or Sickness; s suicide or attempted suicide, while sane or insane; s rest care or rehabilitative care and treatment; s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse: s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or s where medical complications have arisen from abortion; s pregnancy of an Eligible Dependent child; s participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.) s committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.) s participation in a contest of speed in power driven vehicles, parachuting or hang gliding; s air travel, except: s as a fare-paying passenger on a commercial airline on a regularly scheduled route; or s as a passenger for transportation only and not as a pilot or crew member; s being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.) s alcoholism or drug addiction; s sex changes; s experimental treatment, drugs or surgery; s Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) s dental or vision services, including treatment, surgery, extractions or x-rays, unless:

s s s s s s s

s resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or s due to congenital disease or anomaly of a covered newborn child. routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care; elective cosmetic surgery; drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider); sterilization and reversal of sterilization; an expense that does not meet the definition of Covered Charges; an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or any expense for which benefits are not payable under your Other Medical Plan.

Premium Changes

The premium rates may be changed by APL at the first anniversary date of this Policy or any premium due date thereafter. No such increase in rates will be made unless 60 days prior notice is given to the Policyholder. Premiums will not increase during the initial 12 months of coverage.

Optionally Renewable

This Policy is renewable at the option of APL. The Policyholder or APL may terminate this Policy on any premium due date after the first anniversary following the Policy Effective Date, subject to 60 days written notice.

Termination of Certificate

Your insurance coverage under this Certificate and any attached riders will end on the earliest of these dates: s the date the Policy terminates; s the end of the grace period if the premium remains unpaid; s the date you no longer qualify as an Insured; s the date you attain age 70 (if you work for an employer employing less than 20 employees); s the date your coverage under your Employer’s Medical Plan ends; or s the date of your death.

Termination of Coverage

Your insurance coverage under this Certificate and any attached riders for a Covered Person will end as follows: s the date the Policy terminates; s the date the Certificate terminates; s the end of the Certificate Month in which APL receives a written request from you to terminate the Covered Person’s coverage; s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or s the date of the Covered Person’s death. APL may end the coverage of any Covered Person who submits a fraudulent claim.

Cobra Continuation of Coverage

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the certificate/policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Group Medical Expense Supplemental Insurance | (10/14) | Birdville ISD

18APSB-22354(TX) MGM/FBS Birdville ISD

MEDlink® IV

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? $0 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

DELTA

Dental PPO & DHMO

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—High & Low Options Network: Delta Dental PPO or Delta Dental Premiere Birdville ISD offers 2 PPO options listed below. YOU DON’T NEED AN ID CARD TO VISIT A PPO DENTIST! Just register for Online Services to print an ID Card or pull it up on your smartphone at the dentist’s office. In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.

Low Plan Benefits and Covered Services* Diagnostic & Preventive Services (Exams, cleanings, x-rays & Sealants) Basic Services (Fillings and simple tooth extractions) Endodontics (root canals)

High Plan

Delta Dental Non-Delta Dental Delta Dental DPO Non-Delta Dental DPO Dentists ** DPO dentists** Dentists *** DPO dentists*** 100%

100%

50%

80%

50%

In-Network

Out-of Network

In-Network

Out-of Network

Individual

$50.00

Family

$150.00

Annual Max Benefit

In-Network

Out-of Network

In-Network

Out-of Network

Per Person Each Calendar Year

$1,250

Orthodontics– Dependent Children to age 26

In-Network

Out-of Network

In-Network

Out-of Network

50%

Other Oral Surgery Major Services (Crowns, inlays, onlays, and cast restorations) Prosthodontics (Bridges, denturs and implants) Deductible

Orthodontic– Dependent Children to age 26 Orthodontic Maximums

$1,000 Lifetime

Monthly Premiums by Plan Tier

Low Plan

High Plan

EE Only

$25.55

$36.12

EE + Spouse

$50.66

$70.47

EE + Child(ren)

$57.14

$80.75

EE + Family

$82.23

$116.23

$1,000 Lifetime

*Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental Contract Allowances and not necessarily each dentist’s actual fees. ** Fees are based on DPO Contracted Fees for DPO dentists, DPO contracted fees for Premier Dentists and DPO contracted fees for non-Delta Dental dentists. *** Fees are based on DPO contracted fees for DPO Dentists, Delta Dental Premier contracted fees for Premier dentists and the 90th percentile for non-Delta Dental dentists.

Dental PPOâ&#x20AC;&#x201D; High & Low Options Low & High PPO Dental Plan Preventive

How Many/How Often:

Prophylaxis (cleanings)

Two in a calendar year

Oral Examinations

Two in a calendar year

Topical Fluoride Applications

One fluoride treatment per calendar year for children up to age 19

X-rays

Full mouth X-rays: one set per 5 years To age 18 - two in a calendar year and over age 18 - one in a calendar year

Sealants

1st permanent molars to age 9 and 2nd permanent molars to age 16

Basic Restorative

How Many/How Often:

Fillings

Replacement: once every 24 months.

Crown, Denture, & Bridge Repair

Once in 24 months.

General Anesthesia

When dentally necessary in connection with oral surgery, extractions or other covered dental services.

Major Restorative

How Many/How Often:

Implants

One in 5 years

Bridges

One in 5 years

Dentures and Partials

One in 5 years

Crowns/Inlays/Onlays Replacement

One in 5 years

Orthodontia

How Many/How Often: Your Children, up to age 26, are covered while Dental Insurance is in effect

Dental DHMO DHMO Plan Name: DeltaCare USA A DHMO plan provides dental benefits through a network of participating primary and specialty care dentists. Participants pay co-pay amounts for covered services and must see an in-network Delta dentist to receive those services. All covered services must be provided by the memberâ&#x20AC;&#x2122;s Primary Care Dentist. Specialty care dentists require a referral and approval. Please refer to the schedule of benefits for full plan details. If terms of this summary and the schedule of benefits differs, the schedule of benefits governs. For a detailed list of services and fees please visit www.mybenefitshub.com/birdvilleisd

Code

Service

Copayment

DIAGNOSTIC TREATMENT D0120 D0150 D0180 D0274 D0330

Periodic Oral Evaluation Comprehensive Oral Evaluation - New or Established Patient Comprehensive Periodontal Evaluation - new or established patient Bitewings - Four Radiographic images - limited to 1 series every 6 months Panoramic Radiographic Image

$0.00 $0.00 $0.00 $0.00 $0.00

PREVENTIVE SERVICES D1110 D1120 D1351

Prophylaxis - Adult Prophylaxis - Child Sealant-per tooth-through age 15

D2140 D2330 D2391

Amalgam - One Surface, Primary or Permanent Resin-Based Composite-One Surface, Anterior Resin-Based Composite - One Surface, Posterior

D2750 D2751

Crown Porcelain Fused to High Noble Metal Crown Porcelain Fused to Predominantly Base Metal

D3220 D3330

Therapeutic Pulpotomy Root Canal - Molar

D4260

Osseous Surgery (Inc Flap Entry) - Four or More Contiguous Teeth or Bounded Teeth Spaces - Per Quadrant Periodontal Scaling & Root Planning - Four or More Contiguous Teeth Per Quadrant Periodontal Maintenance

DHMO Monthly Premiums Tier

Low Plan

EE Only

$11.66

EE + Spouse

$22.15

EE + Child(ren)

$23.31

EE + Family

$36.12

$5.00 $5.00 $15.00

RESTORATIVE SERVICES $8.00 $22.00 $65.00

CROWNS $395.00 $295.00

ENDODONTICS $45.00 $365.00

PERIODONTICS D4341 D4910

$385.00 $60.00 $45.00

PROSTHODONTICS D5110 D5120 D5211 D5212

Complete Denture - Maxillary Complete Denture - Mandibular Partial Denture - Resin Base - Maxillary Partial Denture - Resin Base - Mandibular

D6211 D6750

Pontic - Cast Predominantly Base Metal Porcelain Crown Fused to High Noble Metal

D7140

Extraction, Erupted Tooth, or Exposed Root (Elevation and/or For- ceps Removal Surgical Removal of Erupted Tooth Removal of Impacted Tooth - Soft Tissue Removal of Impacted Tooth - Completely Bony

$365.00 $365.00 $325.00 $325.00

CROWNS/FIXED BRIDGES $295.00 $395.00

ORAL SURGERY D7210 D7220 D7240

$14.00 $55.00 $70.00 $120.00

ORTHODONTICS D8070 D8080 D8090

Comprehensive Orthodontic Treatment of Transitional Dentition (Full Treatment Case up to 24 Months) Comprehensive Orthodontic Treatment of Adolescent Dentition (Full Treatment Case up to 24 Months) Comprehensive Orthodontic Treatment of Adult Dentition (Full Treatment Case up to 24 Months)

$1,900.00 $1,900.00 $2,100.0

ADJUNCTIVE GENERAL SERVICE D9110 D9310

Palliative (Emergency) Treatment of Dental Pain - Minor Procedure Consultation

$20.00 $25.00

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 Vision Plan Name: Members pay a co-pay for in-network benefits. Out-of-network vision services are reimbursed up to a certain dollar amount for covered expenses. The in-network exam co-pay is $10.00 and the materials co-pay is $25.00.Exams, lenses and frames (within plan allowance) are covered in-network with a co-pay, once every 12 months. CO-PAYS

Vision Plan Benefits Benefits

In-Network

Out-of-Network

Exam

$10

Exam (ophthalmologist) Exam (optometrist)

Covered in full Covered in full

Up to $42 retail Up to $37 retail

$25

Frames

$125 retail allowance

Up to $68 retail

Materials₁ Contact Lens Fitting (standard & specialty)

Contact Lens fitting (standard₂)

Covered in full

Not Covered

Contact Lens fitting (specialty₂) Contact Lenses

$50 retail allowance

Not Covered

Exam

$120 retail allowance

Up to $100 retail

Frame Contact Lens Fitting

SERVICES/FREQUENCY

Lenses (standard) per pair Single Vision Bifocal

Covered in full Covered in full

Up to $32 retail Up to $46 retail

Trifocal Progressive

Covered in full See description₃

Up to $61 retail Up to $61 retail

$25

Lenses Contact Lenses

12 months 12 months 12 months 12 months 12 months

Monthly Premiums EE Only EE + SP EE+ Child(ren) EE + Family

$9.23 $18.28 $17.93 $27.24

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 1

Materials co-pay applies to lenses and frames only, not contact lenses ₂See your benefits materials for definitions of standard and specialty contact lens fittings ₃Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4Contact lenses are in lieu of eyeglass lenses and frames benefit

CIGNA 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 Long Term Disability (LTD) Insurance Coverage Eligibility Eligibility Waiting Period

Monthly Benefit

Elimination Period

If you are an active employee who works at least 20 hours per week, you are eligible on the first of the month following 30 days actively at work. No waiting period. Flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66.67% of your current monthly earnings. Benefit Amount Your benefit amount will be reduced by any amounts payable to you by any of the sources listed under the “Effects of Other income Benefits” section. Maximum $7,500 per month Select from Six Options: Accident/Sickness 0 days/7 days* 14 days/14 days* 30 days/30 days* 60 days/60 days 90 days/90 days 180 days/180 days *If because of your disability, you are hospital confined an inpatient, benefits begin on the first day of inpatient confinement

Important Definitions and Features

Monthly Rates by Type of Plan (Per $100 Benefit)

Definition of Disability “Disability” or “Disabled” means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 80% or more of your indexed earnings. We will require proof of earnings and continued disability.

Covered Earnings “Covered Earnings” means your wages or salary, not including bonuses, commissions, and other extra compensation.

Duration

Acc Sick

EP (Days)

Acc Sick

All Ages

Normal Retirement Age Normal Retirement Age 0 7

14 14

30 30

60 60

90 90

180 180

$4.31

$3.44

$2.84

$1.95

$1.68

$1.29

Monthly Rates by Type of Plan (Per $100 Benefit) Duration

Acc Sick

EP (Days)

Acc Sick

All Ages

Normal Retirement Age Normal Retirement Age

0 7

14 14

30 30

60 60

90 90

180 180

$3.85

$3.04

$2.54

$1.73

$1.50

$1.17

Maximum Benefit Duration

When Benefits Begin You must be continuously Disabled for your elected benefit waiting period before benefits will be payable for a covered Disability.

Age at Disability Duration of Payments (Accident and Sickness)

Under 60

60 -64

65-69

70 and over

To age 65, but not less than 5 years

5 years

To age 70, but not less than 1 year

1 year

Long Term Disability Termination of Disability Benefits

Pre-existing Condition Limitation

Your benefits will terminate when your Disability ceases, when your benefit duration period is exceeded, or on the following events: (1) the date you earn from any occupation more than 80% of your Covered Earnings, or the date you fail to cooperate with us in a rehabilitation plan, or transitional work arrangement, or the administration of the claim.

Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a pre-existing condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Effects of Other Income Benefits This plan is structured to prevent your total benefits and postdisability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan’s benefits by Other Income Benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Disability benefits maybe reduced by amounts received through Social Security disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will also be reduced by amounts received through other government programs, sick leave, employer’s sabbatical leave, employer’s assault leave plan, employer funded retirement benefits, workers’ compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your outline of coverage, policy certificate, or your employer’s summary plan description. Note: Some of the Other Income Benefits, as defined in the group policy, will not be considered until after disability benefits are payable for 6 months.

Additional Plan Details & Features Earnings While Disabled During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability Covered Earnings. After that, benefits will be reduced by 50% of earnings from employment.

Pre-existing Condition Waiver The Insurance Company will waive the Pre-Existing Condition Limitation for the first month of Disability even if the Employee has a Pre-Existing Condition. The Disability Benefits as shown in the Schedule of Benefits will continue beyond 1 month only if the Pre-Existing Condition Limitation does not apply.

Limited Benefit Period Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months for outpatient treatment: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses) ,alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime outpatient limit is exhausted.

Exclusions This plan does not pay benefits for a Disability which results, directly or indirectly, from any of the following:  Suicide, attempted suicide, or intentionally self-inflicted injury while sane or insane;  war or any act of war, whether or not declared;  active participation in a riot;  commission of a felony;  the revocation, restriction or non-renewal of an Employee’s license, permit or certification necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness otherwise covered by the Policy;  any cosmetic surgery or surgical procedure that is not Medically Necessary;  an Injury or Sickness for which the Employee is entitled to benefits from Workers’ Compensation or occupational disease law;  an Injury or Sickness that is work related. In addition, the plan does not pay disability benefits any period of Disability during which you are incarcerated in a penal or corrections institution.

Long Term Disability Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

When Coverage Takes Effect Your coverage takes effect on the later of the policy’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you’re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on the date you return to work. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you.

Rehabilitation Requirement To be eligible for Disability benefits under this plan, you may be required to participate in a rehabilitation plan at the sole discretion and expense of the insurance company or company administering benefits under this plan. If you fail to fully cooperate with the rehabilitation plan, no Disability benefits will be paid, and coverage will end. For details, see your Certificate of Insurance.

Terms and conditions of coverage for Long-Term Disability insurance are set forth in Group Policy No. SLH100006. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, are contained in the Policy Certificate. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192. “Cigna” and the “Tree of Life” logo 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, including Life Insurance Company of North America and Cigna Life Insurance Company of New York, and not by Cigna Corporation.

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

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.

GC3 Limited Benefit Group Cancer Indemnity Insurance Birdville 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 NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits* Benefits

Level 1 Base Plan

Level 2 Base Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$1,000 per calendar month of treatment

$1,500 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

$3,200 max per operation; $30 per surgical unit

$4,800 max per operation; $45 per surgical unit

Anesthesia Benefit

25% of the amount paid for covered surgery

Hospital Confinement Benefit

$200 per day 1-90 days; $200 per day, 91+ days in lieu of other benefits

$300 per day 1-90 days; $300 per day, 91+ days in lieu of other benefits

US Government/Charity Hospital/HMO

$200 per day in lieu of most other benefits

$300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$400 per day of surgery

$600 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

Drugs & Medicine Benefit - Outpatient

$50 per prescription, up to $100 per calendar month

$50 per prescription, up to $150 per cal month

Transportation & Outpatient Lodging Benefit

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

Family Member Transportation & Lodging Benefit

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year

Blood, Plasma & Platelets Benefit

$200 per day, up to $10,000 per calendar year

$250 per day, up to $12,500 per calendar year

Bone Marrow/Stem Cell Transplant

Autologous - $1,000 per calendar year Non-Autologous - $3,000 per calendar year

Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year

Experimental Treatment Benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$40 per day of confinement

$50 per day of confinement

Surgical Prosthesis Benefit

$2,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

$3,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

$200 per day, 1-90 days of hospital confinement

$300 per day, 1-90 days of hospital confinement

Hospice Care Benefit

$75 per day, $13,500 lifetime max

$100 per day, $18,000 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

Ambulance Air Benefit

$2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air)

Extended Care Benefit

$200 per day

$300 per day

Home Health Care Benefit

$200 per day

$300 per day

Second & Third Surgical Opinions

$300 per diagnosis; additional $300 if third opinion required

Waiver of Premium

Premium waived after 90 days of primary insured continuous total disability due to cancer

Physical/Speech Therapy Benefit

$25 per visit, up to 4 visits per calendar month, $1,000 lifetime max

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

Critical Illness Rider: Heart/Stroke

$2,500 lump sum benefit

Up to $800 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Riders

Optional Benefit Rider Intensive Care Unit Rider Monthly Premium**

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$22.00

$26.40

$29.90

$34.30

One Parent

$30.30

$36.30

$40.90

$46.90

$38.50

$47.70

$51.90

$61.10

Two Parent

*Premium and amount of benefits provided vary dependent upon the level selected at time of application. **Total premium includes the policy and riders of the option selected.

APSB-22356(TX) MGM/FBS Birdville ISD-0315

GC3 Limited Benefit Group Cancer Indemnity Insurance Eligibility

This policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage. If You are working either under contract to or as a Full-Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us.

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer. No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

Diagnostic Testing Benefit Rider

We will pay the indemnity amount for one generally medically recognized internal cancer screening test per covered person per calendar year. Screening test include, but limited to: mammogram; breast ultrasound; breast thermography; breast cancer blood test (CA15-3); colon cancer blood test (CEA); prostate-specific antigen blood test (PSA); flexible sigmoidoscopy; colonoscopy; virtual colonoscopy; ovarian cancer blood test (CA-125); pap smear (lab test required); chest x-ray; hemocult stool specimen; serum protein electrophoresis (blood test for myeloma); thin prep pap test. Screening tests payable under this benefit will only be paid under this benefit. Benefits will only be paid for tests performed after the 30-day period following the covered person’s effective date of coverage.

APSB-22356(TX) MGM/FBS Birdville 34

ISD-0315

Critical Illness Rider

Benefits will only be paid for a covered critical illness as shown on the policy/ certificate schedule page in the policy. No benefits will be provided for any loss caused by or resulting from: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; or alcoholism or drug addiction; or any act of war, declared or undeclared , or any act related to war; or military service for any country at war; or a pre-existing condition; or a covered critical illness when the date of diagnosis occurs during the waiting period; or participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in a felony, riot or insurrection (a felony is as defined by the law of the jurisdiction in which the activity takes place). Internal cancer does not include: other conditions that may be considered pre-cancerous or having malignant potential such as: acquired immune deficiency syndrome (AIDS); or actinic keratosis; or myelodysplastic and non-malignant myeloproliferative disorders; or aplastic anemia; or atypia; or non-malignant monoclonal gamopathy; or Leukoplakia; or Hyperplasia; or Carcinold; or Polycythemia; or carcinoma in situ or any skin cancer other than invasive malignant melanoma into the dermis or deeper. For a pre-existing condition no benefits are payable. Pre-Existing Condition, as used in this rider means any sickness or condition for which prior to the Effective Date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment.

Hospital Intensive Care Unit Rider

No benefits will be provided during the first two years of this rider for hospital intensive care unit confinement caused by any heart condition when any heart condition was diagnosed or treated prior to the 30th day following the covered person’s effective date of this rider. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. No benefits will be provided if the loss results from: attempted suicide, whether sane or insane; or intentional self-injury; or alcoholism or drug addiction; or any act of war, declared or undeclared, or any act related to war; or military service for a country at war. No benefits will be paid for confinements in units such as surgical recovery rooms, progressive care, burn units, intermediate care, private monitored rooms, observation units, telemetry units or psychiatric units not involving intensive medical care; or other facilities which do not meet the standards for intensive care unit as defined in the rider. For a newborn child born within the tenmonth period following the effective date of this rider, no benefits will be provided for hospital intensive care unit confinement that begins within the first 30 days following the birth of such child.

GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

This policy/certificate is conditionally renewable. This means that We have the right to terminate your policy/certificate on any premium due date after the first Policyholder’s Anniversary Date. We must give the Policyholder at least 60 days written notice prior to cancellation. We cannot cancel Your coverage because of a change in Your age or health. We can change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums.

Continuation Rider Continuation

Coverage is continued when the Insured (You) cease employment with the employer through whom You originally became insured under the Policy. You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our home office. Premiums must be paid within thirty-one (31) days after employment with your employer terminates. Premium rates required under this Continuation provision will be the same rates as those charged under the Employer’s Policy as if You had continued employment. We will bill You for these premiums after You notify Us to continue this coverage. Coverage will continue until the earlier of: (1) the Policy under which You originally became insured ends; or (2) You stop paying premiums under this option (subject to the terms of the Grace Period).

Termination of Coverage

Your Insurance coverage will end on the earliest of these dates: (a) the date You no longer qualify as an Insured; (b) the last day of the period for which a premium has been paid, subject to the Grace Period; (c) the date the Policy terminates (See Conversion provision); (d) the date You retire; (e) the date You cease employment, or terminate Your contract with the employer through whom You originally became insured under the Policy (See Conversion provision); or (f) the date We receive Your written request for termination. Termination of Dependent(s) Insurance coverage on Your Dependent(s) will end on the earliest of these dates: (a) the date the coverage under the Certificate terminates; (b) the date the Dependent no longer meets the definition of Dependent, as defined in the Policy/Certificate (See Conversion provision); (c) the date We receive Your written request for termination.

Termination of Rider Coverage

This rider terminates: (a) when Your coverage terminates under the Policy/ Certificate to which this Rider is attached; or, (b) when any premium for this rider is not paid before the end of the Grace Period; or, (c) when You give Us a written request to do so. Coverage on a Dependent terminates under this rider when such person ceases to meet the definition of Dependent, as defined in the Policy.

Conversion

If the Employer’s Policy is terminated, this Certificate will terminate. Upon termination of the Employer’s Policy, the employee (You) will be entitled to convert to an individual policy of insurance issued by Us without evidence of insurability provided the required premiums have been paid on your behalf and You notified Us in writing within thirty-one (31) days of the Employer’s Policy termination. Premiums for the individual policy of insurance will be figured from the premium rate table in effect on the date of conversion. Subject to the terms of this provision, a covered child who ceases to be eligible may convert to an individual policy of insurance and a covered spouse who ceases to be eligible for coverage because of divorce or annulment may convert to an individual policy. Terms of this provision include: (1) Application for the individual policy and payment of the first premium must be made within 60 days after coverage ceases under the Policy/Certificate. Premiums will be figured from the premium rate table in effect on the date of conversion. (2) The individual policy will be issued without proof of insurability. It will provide benefits that most nearly approximates those of the Policy/Certificate. (3) The individual policy will take effect the day after coverage ceases under the Policy/Certificate. However, no benefits will be payable under the individual policy for any loss for which benefits are payable under the Policy/Certificate. (4) The Pre-Existing Condition Limitation and Time Limit on Certain Defenses provisions for the individual policy will be figured from the Covered Person’s Effective Date of coverage under the Policy/ Certificate. (5) Any benefit maximums will be figured from the Effective Date of the Policy/Certificate. This rider is subject to all the provisions of the Policy and Certificate to which it is attached that are not in conflict with this rider.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy/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 GC-3 Series | Texas | Limited Benefit Group Cancer Indemnity Insurance Policy | (11/14) | Birdville ISD

APSB-22356(TX) MGM/FBS Birdville ISD-0315

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 For New Hires  The enrollment takes place within 31 days from the date Employee Coverage you become eligible for benefits, and $10,000 increments to a maximum of the lesser of 7 times your  You are enrolling your spouse for coverage equal to/less basic annual earnings or $500,000. than $50,000. Dependent Coverage If you do not meet all of the conditions stated above, you will You must be enrolled in voluntary employee life benefits to be need to provide additional medical information by completing a eligible for benefits on your dependent(s) Spouse - $5,000 increments to a maximum of the lesser of 100% Statement of Health form. of your Life Benefits or $250,000. Voluntary AD&D Dependent Children - $10,000. *Child(ren)’s Eligibility: Dependent children ages from live birth Employee Coverage to 26 years old are eligible for coverage  Increments of $10,000 The maximum amount of coverage you can receive is $500,000, Guarantee Increase of Benefit : not to exceed 10 times annual salary If eligible, this benefit allows you to increase your coverage Dependent Coverage every year as your life insurance needs change. You may You can choose to cover your dependent spouse and child(ren) increase your benefit amount by $10,000, and your spouse by with AD&D coverage under the Family Plan. Your dependents $5,000 every year until you reach your maximum amount, will be eligible for the following coverage: without providing Evidence of Insurability. Dependent Spouse and Child(ren):  Spouse — 50% of your coverage amount For New Hires:  Child(ren) — 10% of your coverage amount  Your enrollment takes place within 31 days from the date you become eligible for benefits, and What Is Not Covered?  You are enrolling for coverage equal to/less than 7 times Accidental Death & Dismemberment insurance does not include your basic annual earnings or $250,000 payment for any loss which is caused by or contributed to by: If you do not meet all of the conditions stated above, you will physical or mental illness, diagnosis of or treatment of the need to provide additional medical information by completing a illness; an infection, unless caused by an external wound Statement of Health form. accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by EE Cost per Spouse Cost per Age a doctor or an over-the-counter drug taken as directed; $10,000 $10,000 voluntary intake of alcohol in combination with any drug, Under 25 $0.40 $0.20 medication or sedative; war, whether declared or undeclared, 25-29 $0.50 $0.25 or act of war, insurrection, rebellion or riot; committing or trying 30-34 $0.70 $0.35 to commit a felony; any poison, fumes or gas, voluntarily taken, 35-39 $0.80 $0.40 administered or absorbed; service in the armed forces of any 40-44 $1.10 $0.55 country or international authority, except the United States 45-49 $1.80 $0.90 National Guard; operating, learning to operate, or serving as a 50-54 $3.20 $1.60 member of a crew of an aircraft; while in any aircraft for the 55-59 $5.00 $2.50 purpose of descent from such aircraft while in flight (except for 60-64 $7.50 $3.75 self preservation); or operating a vehicle or device while 65-69 $11.50 $5.75 intoxicated as defined by the laws of the jurisdiction in which 70 & Over $18.50 $9.25 the accident occurs. Cost for your Child $1.20 (ren)*

Supplemental Term Life

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

AD&D Supplemental Coverage

Monthly Cost per $10,000

Employee

$0.21

Employee & Family

$0.29

ID WATCHDOG

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 Identity theft can strike anyone, at any time.

ID Watchdog Monthly Rates

More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

Identity theft devastates its victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.

Repairing the damage caused by identity theft is frustrating and time consuming.

Individual Plan

$7.95

Family Plan

$14.95

ID Watchdog Services       

Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee

The average victim spends 330 hours repairing the damage from identity theft—the equivalent of working a full-time job for more than 2 months.

The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.

Who’s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

METLAW YOUR BENEFITS PACKAGE

Legal Services

About this Benefit Having an affordable, qualified lawyer on your side can be an invaluable asset. Legal plans provide valuable benefits that cover the most common legal needs you may encounter - like creating a standard will, living will, healthcare power of attorney or buying a home. This plan also provides access to quality law firms for advice, consultation and representation.

DID YOU KNOW?

55% of American adults do not have a will or other estate plan in place.

Legal Services Provides you with telephone and office consultations for an unlimited number of matters with the network attorney of your choice. Telephone & Office Consultations MetLaw provides you with telephone and office consultations for an unlimited number of matters with the attorney of your choice. During the consultation, the attorney will review the law, discuss your rights and responsibilities, explore your options and recommend a course of action.

Legal Representation Trials for covered matters are covered from beginning to end, regardless of length, when using a network attorney.

Estate Planning Documents

Financial Matters

Real Estate Matters

Elder Law Matters

Sale, Purchase or Refinancing of your Primary, Second or Vacation Home Home

Consultation and Document Review for Issues Related to your Parents:

Simple Wills Personal Bankruptcy/Wage Earner Plan Complex Wills Revocable Trusts Irrevocable Trusts Powers of Attorney Debt Collection Defense (Healthcare, Financial, Childcare) Equity Loans for your Primary, Second or Healthcare Proxies Foreclosure Defense Vacation Home Living Wills Codicils

Medicare Medicaid

Repossession Defense

Tenant Negotiations (Tenant Only)

Prescription Plans

Garnishment Defense

Eviction Defense

Nursing Home Agreements

Identity Theft Defense

Security Deposit Assistance (Tenant Only)

Leases

Tax Collection Defense

Notes Boundary or Title Disputes

Negotiations with Creditors Tax

Deeds Property Tax Assessments

Audit Representation (Municipal, State, Federal)

Wills Zoning Applications Powers of Attorney

Family Law

Traffic Offenses*

Document Preparation

Immigration Assistance

Adoption

Defense of Traffic Tickets (Excludes DUI)

Affidavits

Advice and Consultation Review of Immigration Documents

Guardianship

Driving Privileges Restoration (Includes License Suspension due to DUI)

Deeds Preparation of Affidavits

Conservatorship

Demand Letters

Name Change

Mortgages

Prenuptial Agreement

Notes

Protection from Domestic Violence

Review of Any Personal Legal Document

Preparation of Powers of Attorney

Juvenile Matters Personal Property Protection

Consumer Protection

Defense of Civil Lawsuits

Property Protection

Juvenile Court Defense (Including Criminal Matters)

Disputes over Consumer Goods and Services

Litigation Defense

Consultation and Document Review for Personal Property Issues

Incompetency Defense Parental Responsibility Matters

Small Claims Assistance Administrative Hearings

Assistance for Disputes over Goods and Services

School Hearings Pet Liabilities

$16.50 Per Month & Covers Employee, Spouse and Dependents.

LifeWorks YOUR BENEFITS PACKAGE

EAP (Employee Assistance Program)

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.

Employee Assistance Program With LifeWorks Integrated EAP and Work-life services, employees and their families will have access to confidential assistance and support on a wide range of issues in the areas of life, health, family, work and money. Topic

Description

Emotions and Stress

Relationship issues, depression and anxiety – even an online “calm room

Parenting

Parenting skills, adoption, talking with your teenager, help in finding child care

Midlife and Retirement

Financial considerations, work and career in midlife, relationships with adult children, growing as a couple

Addictive Behaviors

Drug and alcohol abuse, eating disorders, gambling

Education

Applying to college, understanding financial aid and scholarships, advocating in the schools

Caring of older adults

Caregiver support, referrals to in-home and other services, and federally funded programs

Disability

Special needs programs, advocacy and specific disabilities information

Everyday Issues

Community resources and consumer information

Financial Issues

Credit management, budget analysis, 401(k) plan questions, basic estate planning, and questions about federal tax planning and preparation

Legal Issues

On-staff attorneys provide information and referrals for family matters, real estate, consumer credit and criminal matters. Also online program with forms, guides and simple wills.

Work

Special content for managers includes employee relations, interpersonal conflicts, performance issues, discrimination and workplace change. Also general support for co-worker relationships and stress.

Employees and their families have anytime access to LifeWorks Integrated EAP and Work-life services in a variety of ways that fit their preferences and unique needs.



Telephone   

All calls are answered live by Ceridian employees who are trained clinical consultants with master’s/doctorate degrees. LifeWorks is a 24/7 operation, so there are no changes in our  service delivery during non-business hours — your employees will not be directed to leave messages. A fully staffed bilingual clinical consultant team answers calls from service centers in St. Petersburg, FL; Minneapolis, MN;  Blue Bell, PA; Toronto, Winnipeg and Montreal, Canada.

Mobile 

An app for mobile devices makes the LifeWorks.com site accessible from anywhere at any time for iPhone, Android and Blackberry users.

In-Person 



Ceridian develops close relationships and carefully evaluates the national network of EAP providers who deliver in-person counseling to your employees. This cohesive team includes consultants that complete the initial screening assessment and connect participants to the EAP provider and EAP affiliate managers to ensure a high quality experience. Ceridian also employs a Clinical Supervisor within Provider Network Services for case consultation and assistance to the local EAP affiliate. Our North American network of 11,300 EAP providers includes all 50 U.S. states, Puerto Rico, the Virgin Islands, Mexico, Canada and U.S. Territories. Our entire network is composed of licensed mental health professionals. Minimum qualifications include a license to practice independently in the state in which services are provided along with five years post graduate experience and three years providing EAP services. Our counselors and providers possess strong EAP and worklife skills, and we aggressively recruit Certified Employee Assistance Professionals (CEAPs) whose focus is on helping employees quickly resolve issues that may interfere with their work.

Employees and their families will have access to face-to-face assessments and short- term, solution-focused counseling with EAP clinicians.

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.

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 need a replacement card please contact NBS directly at (800) 274-0503.

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

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!

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

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

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

FSA Annual Contribution Max: $2,550

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 claims FAQs 45

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

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

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/ birdvilleisd 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 or rollover after the Plan year ends for you to submit qualified claims for any unused funds.

NBS

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.

HSA (Health Savings Account) What is an HSA?

Participant Account Web Access:

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www.nbsbenefits.com A Health Savings Account (HSA) works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck - before taxes– into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses. *If you enroll in HSA you are no eligible for MEDlink®insurance or an FSA account.

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A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, coinsurance, prescriptions, vision and dental care. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. Potential to build more savings through investing. If you maintain a minimum balance of $2,000, your additional funds may be invested in mutual funds yielding tax-free earnings. Additional retirement savings. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for non-eligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.

Pre-Paid Debit Card You may use the card to pay merchants or service providers that accept Master Card credit cards, so there is no need to pay cash up front then wait for reimbursement.

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch-up” contribution to their HSA.

Will my HSA Funds be Up Fronted to Me?

A Health Savings Account (HSA):  Grows with you. If you maintain a balance of $2,000, your additional funds may be invested in mutual funds yielding tax-free earnings.  Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for non-eligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties. For a list of sample expenses, please refer to www.mybenefitshub.com/birdvilleisd

NBS Contact Information P.O. Box 6980 West Jordan, UT 84084 Phone‐800‐274-0503 Fax‐800-478-1528 Email: service@nbsbenefits.com

Like a savings account, you can only withdrawal what you’ve contributed to the account. Funds are not up fronted.

Are There Any Monthly Fees? There is a $2.00 administrative fee that will be deducted from your HSA account on a monthly basis.

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