2016 Benefit Guide Lake Worth ISD by Higginbotham Public Sector

LAKE WORTH ISD

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

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. HSA vs FSA Comparison TRS-ActiveCare Medical TRS Baylor Scott & White Medical NBS Flexible Spending Account MEDLink® Medical Supplement Aetna Dental VSP Vision Reliance Standard Disability Loyal American Cancer Allstate Critical Illness AUL a OneAmerica Company Life & AD&D ID Watchdog Identity Theft Protection HSA Bank Health Savings Account (HSA)

3 4-5 6-11 6 7 8 9 10 11 12-15 16-17 18-21 22-25 26-29 30-31 32-35 36-39 40-41 42-45 46-47 48-51

FLIP TO... PG. 4 HOW TO ENROLL

PG. 6 YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 12 YOUR MEDICAL BENEFITS

Benefit Contact Information

Benefit Contact Information LAKE WORTH ISD BENEFITS Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/ lakeworthisd LAKE WORTH ISD BENFITS OFFICE Maria Castillo or Leslie Reyes (817) 306-4200 ext 1048 or 1049 MCastillo@lwisd.org or LReyes@lwisd.org

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

MEDICAL SUPPLEMENT— MEDLINK ® Group #15302 American Public Life (800) 256-8606 www.ampublic.com

DISABILITY

LIFE AND AD&D

Group #VPL683271 Reliance Standard (800) 351-7500 www.reliancestandard.com

Group #GFZ02331 AUL a OneAmerica Company (800) 583-6908 www.oneamerica.com

CANCER

ID THEFT PROTECTION

Loyal American (800) 366-8354 www.loyalamerican.com

ID Watchdog (800) 237-1521 www.idwatchdog.com

TRS ACTIVECARE MEDICAL

DENTAL

CRITICAL ILLNESS

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

Aetna (877) 238-6200 www.aetna.com

Allstate (800) 348-4489 www.allstateatwork.com

TRS HMO MEDICAL

VISION

Scott and White Health (800) 321-7947 www.trs.swhp.org

Group #12243999 VSP (800) 877- 7195 www.vsp.com

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

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

TEXT

need to complete your enrollment.

“lakeworth”

Avoid typing long URLs and scan directly to your benefits website,

313131

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

TRY ME

SCAN:

On Your Computer Access THEbenefitsHUB from your

Our online benefit enrollment

computer, tablet or smartphone!

platform provides a simple and easy to navigate process. Enroll at your own pace, whether at home or at work. www.mybenefitshub.com/ lakeworthisd 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/lakeworthisd

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

Username:

Sample Username

lincola1234 Sample Password

The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

lincoln1234

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

If you have trouble

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

logging in, click on the

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

“Login Help Video”

your Social Security Number.

for assistance.

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

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  NEW! All plans offered by Lake Worth ISD become

effective on 9/1/16 and remain in effect until 8/31/17. For 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. Changes must be made within 31 days of event.  Aetna remains the carrier for TRS ActiveCare Medical

Plans: ActiveCare 1 HD, ActiveCare 2 and ActiveCare Select. Scott and White HMO Plan is available for all employees working or residing in Dallas, Ellis, Denton, Collin, Rockwall and Tarrant counties. All eligible employees, including active, contributing TRS members and employees regularly working 10 hours per week MUST either enroll for coverage or decline coverage in the Benefits HUB. For comprehensive TRS medical information, please visit www.trs.state.tx.us.  LWISD provides $50,000 of Basic Term Life and AD&D

 NEW! Lake Worth now offers enrollment in a Health

Savings Account which are administered by HSA Bank. An HSA allows you to contribute funds pre-taxed into your account that can be used for medical, dental, vision, and prescription expenses. The IRS annual maximums are determined by the participants enrolled in the High Deductible Health Plan, Active Care 1 HD: $3350 for an individual or $6750 for your family. When you enroll in an HSA, you will receive a welcome packet and verification instructions to receive your new debit card no earlier than mid-September. Fund balances rollover from year to year but annual enrollment is required during open enrollment. If you elect the MEDLink® plan, Active Care Select or ActiveCare 2, you are not eligible to participate in an HSA.  NEW! Lake Worth now offers group Cancer though Loyal

American and Group Critical Illness through Allstate. Enrollment is guaranteed issue and requires no paper applications. You may enroll in coverage for yourself, your spouse and your children.

insurance to all eligible employees through One America. Voluntary Life for employees, spouses, and children is also available. New hire Guarantee Issue (GI) is up to 7  National Benefit Services remains the administrator of times salary or $200,000; $50,000 for spouse and your Flexible Spending and Childcare Reimbursement $10,000 for children. All current employees and spouse Accounts. You MUST re-elect a new contribution amount coverage amounts can increase by $10,000 up to the GI every year to participate. This benefit does NOT rollover. amount with no health questions asked. Your entire annual contribution amount will be available to use 9/1/16. Claim forms are available on the benefits website at www.mybenefitshub.com/lakeworthisd.

Don’t Forget!  Lake Worth will conduct Open Enrollment from July 18th though August 22. Per ACA requirements and LWISD protocol, all LWISD employees are required to either elect or decline medical and supplemental benefits during the open enrollment period.  Enrollment assistance is available by using the “Contact Us” link on the website or by calling Financial Benefit Services Call Center at (866) 914-5202 Monday-Friday, July 18th through August 22th from 8am - 5pm to speak to a representative. Spanish speaking representatives will be available.  Please have spouse and dependent's Social Security numbers and dates of birth available when completing your enrollment. 6

SUMMARY PAGES

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

CHANGES IN STATUS (CIS): Marital Status

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

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

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

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website:

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

the forms you need under the Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

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

notify your employer of any discrepancy in personal and/or

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

benefit information.



For benefit summaries and claim forms, go to the Lake Worth

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

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

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

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

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

SUMMARY PAGES

must be actively-at-work on September 1, 2016 to be eligible for

Employee Eligibility Requirements

your new benefits.

Dependent Eligibility Requirements

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

Dependent Eligibility: You can cover eligible dependent Eligible employees must be actively at work on the plan effective

children under a benefit that offers dependent coverage,

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

provided you participate in the same benefit, through the

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

maximum age listed below. Dependents cannot be double

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

covered by married spouses within Lake Worth ISD or as both

your 2016 benefits become effective on September 1, 2016, you

employees and dependents.

PLAN

CARRIER

MAXIMUM AGE

TRS Medical

Aetna

Dental

Aetna

Vision

VSP

Cancer

Loyal American

Critical Illness

Allstate

MEDLink IV*

APL

Life and AD&D

AUL a OneAmerica Company

*Contact carrier within 30 days of termination to be eligible for continuation

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

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

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

N/A Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO… PG. 48

FLIP TO… PG. 18

FOR HSA INFORMATION

FOR FSA INFORMATION

TRS Aetna

Medical

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

More than 70% of adults across the United States are already being diagnosed with a chronic disease.

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 Lake Worth ISD Benefits Website: www.mybenefitshub.com/lakeworthisd 12

Lake Worth ISD 2016 - 2017 TRS Medical Rates TRS-ActiveCare Plan 1HD

TRS Monthly Premium

Lake Worth ISD Contribution

2016-2017 TRS Employee Premium

Employee Only

$341.00

$225.00

$116.00

Employee & Spouse

$914.00

$225.00

$689.00

Employee & Child(ren)

$615.00

$225.00

$390.00

Employee & Family

$1,231.00

$225.00

$1,006.00

Deductible: Employee Only $2500 & Employee Family $5000 Max Out of Pocket: Employee Only $6550 & Employee Family $13,100

TRS-ActiveCare SelectExclusive Provider Organization

TRS Monthly Premium

Lake Worth ISD Contribution

2016-2017 TRS Employee Premium

Employee Only

$484.00

$225.00

$259.00

Employee & Spouse

$1,147.00

$225.00

$922.00

Employee & Child(ren)

$779.00

$225.00

$554.00

Employee & Family

$1,361.00

$225.00

$1,136.00

Deductible: Employee Only $1200 Ded & Employee Family $3600 Ded Max Out of Pocket: Employee Only $6850 & Employee Family $13,700

TRS-ActiveCare 2

TRS Monthly Premium

Lake Worth ISD Contribution

2016-2017 TRS Employee Premium

Employee Only

$645.00

$225.00

$420.00

Employee & Spouse

$1,552.00

$225.00

$1,327.00

Employee & Child(ren)

$1,042.00

$225.00

$817.00

Employee & Family

$1,597.00

$225.00

$1,372.00

Deductible: Employee Only $1200 & Employee Family $3000 Max Out of Pocket: Employee Only $6850 & Employee Family $13,700

Scott and White HMO

TRS Monthly Premium

Lake Worth ISD Contribution

2016-2017 TRS Employee Premium

Employee Only

$503.60

$225.00

$278.60

Employee & Spouse

$1,135.62

$225.00

$910.62

Employee & Child(ren)

$798.30

$225.00

$573.30

Employee & Family

$1,259.76

$225.00

$1,034.76

Deductible: Employee Only $1000 Ded & Employee Family $3000 Max Out of Pocket: Employee Only $5000 & Employee Family $10,000

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

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

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

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

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

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

$6,850 individual $13,700 family

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

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

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

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

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

Plan pays 100%

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

20% after deductible

$100 copay plus 20% after deductible

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

20% after deductible

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

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

Emergency Room (true emergency use) Participant pays

20% after deductible

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

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

Not covered

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

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

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

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

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

$20 $40** $65**

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

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

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

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

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

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

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www. uspreventiveservicestaskforce.org/Page/Name/uspstf-a-andbrecommendations.

Plan pays 100% (deductible waived)

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

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

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

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

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

$60 copay for specialist

$50 copay for specialist

Annual Hearing Examination Participant pays

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

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

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

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

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

Copay

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

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

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

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

FSA (Flexible Spending Account) Available Benefits Health flexible spending account:

considered “incurred” when the service is performed, not necessarily when it is paid for. You can get submit a claim online at: my.nbsbenefits.com

The health flexible spending account (FSA) enables you to pay for expenses allowed under Section 105 and 213(d) of the Internal Please note: Policies other than company sponsored policies (i.e. Revenue Code which are not covered by our insured medical spouse’s or dependents’ individual policies) may not be paid plan. through the flexible benefits plan. Furthermore, qualified longterm care insurance plans may not be paid through the flexible The most that you can contribute to your Health FSA each plan benefits plan. year is set by the IRS. This amount can be adjusted for increases in cost-of-living in accordance with Code Section 125(i)(2). Account Information

A Participants may call NBS and talk to a representative during our regular buisiness hours, Monday-Friday, 7 a.m. to 6 p.m. A premium expense portion of the plan allows you to use pre- tax Mountain Time. Participants can also obtain account information dollars to pay for specific premiums under various insurance using the Automated Voice Response Unit, 24 hours a day, 7 days programs we offer you. a week at (801) 838-7324 or toll free at (888) 353-9125. For immediate access to your account information at any time, log Dependent care flexible spending account: on to our website at my.nbsbenefits.com or download the NBS The dependent care flexible spending account (DCFSA) enables Mobile App. you to pay for out-of-pocket, work-related dependent daycare costs. Please see the Summary Plan Description for the definition of an eligible dependent. The law places limits on the amount of What Can I Save with an FSA? money that can be paid to you in a calendar year.

Current plan participants:

Generally, your reimbursement may not exceed the lesser of: (a) $5,000 (if you are married filing a joint return or you are head of a household) or $2,500 (if you are married filing separate returns); (b) your taxable compensation; (c) your spouse’s actual or deemed earned income. Also, in order to have the reimbursements made to you and be excluded from your income, you must provide a statement from the service provider including the name, address and, in most cases, the taxpayer identification number of the service provider as well as the amount of such expense and proof that the expense has been incurred.

Determining contributions

FSA Annual taxable income

$24,000

Health FSA

$1,500

Dependent care FSA

$1,500

Total pre-tax contributions

-$3,000

Taxable income after FSA

$21,000

$24,000

-$6,300

-$7,200

$14,700

$16,800

-$3,000

$14,700

$13,800

$900

Before each plan year begins, you will select the benefits you Income taxes want and how much contributions should go toward each benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered benefit or After-tax income expense during the plan year. Generally, you cannot change the elections you have made after After-tax health and welfare expenses the beginning of the plan year. However, there are certain limited situations when you can change your elections if you have Take-home pay a “change in status”. Please refer to your Summary Plan Description for a change in status listing

How do I receive reimbursements?

No FSA

You saved

During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are 19

NBS Mobile App Easy and Convenient  

Designed to work just as other iOS and Android apps which makes it easy to learn and use. Shares user authentication with the NBS portal. Registered useres can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

It’s secure No sensitive account information is ever stored on your mobile device and secure encryption is used to protect all transmissions.

Mobile App Features The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account.            

View account balances View claims View reimbursement history Submit claims Submit documentation using your device’s camera Pay providers Setup a variety of SMS alerts Edit your personal information View contribution details View plan information View calendar deadlines Contact a service representative

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

Sample Expenses Dental Expenses 

Acupuncture Addiction programs Adoption (medical expenses for baby birth) Alternative healer fees Ambulance Body scans Breast pumps Care for mentally handicapped Chiropractor Copayments Crutches Diabetes (insulin, glucose monitor)

          

Eye patches Fertility treatment First aid (i.e. bandages, gauze) Hearing aids & batteries Hypnosis (for treatment of illness) Incontinence products (i.e. Depends, Serene) Joint support bandages and hosiery Lab fees Monitoring device (blood pressure, cholesterol) Physical exams Pregnancy tests

       

Prescription drugs Psychiatrist/psychologist (for mental illness) Physical therapy Speech therapy Vaccinations Vaporizers or humidifiers Weight loss program fees (if prescribed by physician) Wheelchair

Vision Expenses

Items that generally do not qualify for reimbursement



      

Artificial teeth Copayments Deductible Dental work Dentures Orthodontia expenses Preventative care at dentist office Bridges, crowns, etc.

      

Vision Expenses        



Braille - books & magazines Contact lenses Contact lens solutions Eye exams Eye glasses Laser surgery Office fees Guide dog and upkeep/other animal aid

  

   

Personal hygiene (deodorant, soap, body powder, sanitary products) Addiction products Allergy relief (oral meds, nasal spray) Antacids and heartburn relief Anti-itch and hydrocortisone creams Athlete’s foot treatment Arthritis pain relieving creams Cold medicines (i.e. syrups, drops, tablets) Cosmetic surgery Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil) Counseling (i.e. marriage/family) Dental care - routine (i.e. toothpaste, toothbrushes, dental floss, antibacterial mouthwashes, fluoride rinses, teeth whitening/bleaching) Exercise equipment Fever & pain reducers (i.e. Aspirin, Tylenol) Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss products) Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal

   

       

Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (ie.e oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e. PeptoBismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppresant

These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition).

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)

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Lake Worth 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

$1,500 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

$250 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

$19.30

$44.38

$32.80

$57.89

Ages 55+

$28.94

$66.57

$49.20

$86.83

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

APSB-22354(TX) MGM/FBS Lake Worth ISD

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Important Policy Provisions Eligibility

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.

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 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. s routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care; s elective cosmetic surgery; s drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider); s sterilization and reversal of sterilization; s an expense that does not meet the definition of Covered Charges; s an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or s any expense for which benefits are not payable under your Other Medical Plan.

Exclusions

Premium Changes

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.

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 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.) APSB-22354(TX)24 MGM/FBS Lake Worth ISD

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.

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance 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) | Lake Worth ISD

APSB-22354(TX) MGM/FBS Lake Worth ISD

AETNA

Dental

YOUR BENEFITS PACKAGE

About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.

DID YOU KNOW?

Good dental care may improve your overall health. Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

Dental Passive PDN and DMO Plans Passive PDN With PDNII Network Participating

DMO

Annual Deductible* Individual None Family None Preventive Services 100% Basic Services 80% Major Services 60% Annual Benefit Maximum None Office Visit Copay $10 Orthodontic Services** $1,500 copay Orthodontic Deductible None Orthodontic Lifetime Maximum *** *The deductible applies to: Basic & Major services only **Orthodontia is covered only for children (appliance must be placed prior to age 20). PDN also includes coverage for adults. *** 24 months of comprehensive orthodontic treatment plus 24 months of retention

Partial List of Services

$75 $225 80% 80% 50% $1,000 N/A 50% None $1,000

DMO

Passive PDN With PDNII Network Participating

100% 100% 100% 100% 100% 100% 100%

80% 80% 80% 80% 80% 80% 80%

80% See Below 80% 80% 80% 80% 80% 80% 80% 80% See Below See Below See Below See Below See Below

80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

Preventative Oral examinations (a) Cleanings (a) Adult/Child Fluoride (a) Sealants (permanent molars only) (a) Bitewing Images (a) Full mouth series Images (a) Space Maintainers

Basic Root canal therapy Anterior teeth / Bicuspid teeth Root canal therapy, molar teeth Scaling and root planing (a) Gingivectomy* Amalgam (silver) fillings Composite fillings (anterior teeth only) Stainless steel crowns Incision and drainage of abscess* Uncomplicated extractions Surgical removal of erupted tooth* Surgical removal of impacted tooth (soft tissue)* Osseous surgery (a)* Surgical removal of impacted tooth (partial bony/ full bony)* General anesthesia/intravenous sedation* Crown Lengthening

Major Inlays 60% Onlays 60% Crowns 60% Full & partial dentures 60% Pontics 60% Root canal therapy, molar teeth 60% Osseous surgery (a)* 60% Surgical removal of impacted tooth (partial bony/ full bony)* 60% General anesthesia/intravenous sedation* 60% Denture repairs 60% Crown Lengthening 60% Crown Build-Ups 60% *Certain services may be covered under the Medical Plan. Contact Member Services for more details. (a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate.

50% 50% 50% 50% 50% See Above See Above See Above See Above 50% See Above 50%

Dental Passive PDN and DMO Plans a.

Other Important Information This benefits summary of the Aetna Dental DMO® (Dental Maintenance Organization) provides information on benefits provided when services are rendered by a participating dentist. In order for a covered person to be eligible for benefits, dental services must be provided by a primary care dentist selected from the network of participating DMO dentists. Under the Dental® Participating Dental Network (PDN) plan, you may 9. choose at the time of service either a PDN participating dentist or any nonparticipating dentist. With the PDN plan, savings are possible because the PDN participating dentists have agreed to provide care for covered services at negotiated rates. Non-participating benefits are 10. subject to usual and prevailing charge limits, as determined by Aetna. Due to state law, limited (varying by state) DMO® benefits for nonemergency services rendered by non-participating providers are available for plan contracts written in: CT, IL, KY and OH and for members residing in MA and OK (regardless of contract situs state).

11. 12. 13.

Emergency Dental Care If you are covered under the DMO plan and need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day, 7 days a week. You should contact your Primary Care Dentist to receive treatment. If you are unable to contact your PCD, contact Member Services for assistance in locating a dentist. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.

14.

15.

When emergency services are provided by a participating PDN dentist, your co-payment/coinsurance amount will be based on a negotiated fee schedule. When emergency services are provided by a non-participating dentist, you will be responsible for the difference between the plan payment and the dentist’s usual charge. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.

Partial List of Exclusions and Limitations* - Coverage is not provided for the following: 1.

3. 4. 5.

6. 7.

Services or supplies that are covered in whole or in part: a. under any other part of this Dental Care Plan; or b. under any other plan of group benefits provided by or through your employer. Services and supplies to diagnose or treat a disease or injury that is not: a. a non-occupational disease; or b. a non-occupational injury. Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate. Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse, misuse or neglect. Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to improve, alter or enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under clinical investigation by health professionals. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or to correct attrition, abrasion or erosion. (This item does not apply to California residents under the DMO plan) Those for any of the following services (Does not apply to the DMO plan in TX):

16. 17.

18. 19. 20. 21.

an appliance or modification of one if an impression for it was made before the person became a covered person; b. a crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person; or c. root canal therapy if the pulp chamber for it was opened before the person became a covered person. Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are prescribed, recommended or approved by the attending physician or dentist. Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate. Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth. Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be eligible for benefits unless done in conjunction with another necessary covered service. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist. Those in connection with a service given to a person age 5 or older if that person becomes a covered person other than: a. during the first 31 days the person is eligible for this coverage, or b. as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to charges incurred: i. after the end of the 12-month period starting on the date the person became a covered person; or ii. as a result of accidental injuries sustained while the person was a covered person; or iii. for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and Pathology. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the services shown in the Dental Care Schedule that applies. Those for a crown, cast or processed restoration unless: a. it is treatment for decay or traumatic injury, and teeth cannot be restored with a filling material; or b. the tooth is an abutment to a covered partial denture or fixed bridge. Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in the BookletCertificate. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the BookletCertificate. Services needed solely in connection with non-covered services. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services. (This item does not apply to California residents under the DMO plan)

Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage. *This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.

Dental Passive PDN and DMO Plans Your Dental Care Plan Coverage Is Subject to the Following Specific products may not be available on both a self-funded and Rules: Replacement Rule The replacement of; addition to; or modification of: existing dentures; crowns; casts or processed restorations; removable denture; fixed bridgework; or other prosthetic services is covered only if one of the following terms is met: The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed. This coverage must have been in force for the covered person when the extraction took place. The existing denture, crown; cast or processed restoration, removable denture, bridgework, or other prosthetic service cannot be made serviceable, and was installed at least 5 years under the Dental DMO plan and 8 years under the Dental PDN plan before its replacement. The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered, and cannot be made permanent, and replacement by a permanent denture is required. The replacement must take place within 12 months from the date of initial installation of the immediate temporary denture. The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.

insured basis. The information in this document is subject to change without notice. In case of a conflict between your plan documents and this information, the plan documents will govern. In the event of a problem with coverage, members should contact Member Services at the toll-free number on their online ID cards for information on how to utilize the grievance procedure when appropriate. All member care and related decisions are the sole responsibility of participating providers. Aetna Dental does not provide health care services and, therefore, cannot guarantee any results or outcomes. Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc. and/or Aetna Health Inc. In Arizona, DMO®, Advantage Dental, Basic Dental and Family Preventive Dental Plans are provided or administered by Aetna Health Inc. In Texas, the Dental Participating Dental Network (PDN) is known as the Participating Dental Network (PDN), and Indemnity Dental plans are provided or administered by Aetna Life Insurance Company.

This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. The availability of a plan or program may vary by geographic Tooth Missing But Not Replaced Rule - (This item does not apply to service area. Certain dental plans are available only for groups of a California or Texas residents under the DMO plan) Coverage for the certain size in accordance with underwriting guidelines. Some benefits first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the requirements that such removable are subject to limitations or exclusions. Consult the plan documents dentures; fixed bridgework and other prosthetic services are (i) needed (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement, Group Policy) to determine to replace one or more natural teeth that were removed while this governing contractual provisions, including procedures, exclusions and policy was in force for the covered person; and (ii) are not abutments to a partial denture; removable bridge; or fixed bridge installed during limitations relating to your plan. the prior 5 years under the Dental DMO plan and 8 years under the Dental PDN plan.

2016 -2017 PDN & DMO Rates

Alternate Treatment Rule: If more than one service can be used to treat a covered person’s dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that all of the following terms are met: a. the service must be listed on the Dental Care Schedule; b. the service selected must be deemed by the dental profession to be an appropriate method of treatment; and c. the service selected must meet broadly accepted national standards of dental practice.

Employee Only

$34.68

Employee + Spouse

$72.91

Employee + Children

$80.71

Employee Family

$116.27

If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service than that for which coverage is approved, the specific copayment for such service will consist of: a. the copayment for the approved less costly service; plus b. the difference in cost between the approved less costly service and the more costly covered service.

Finding Participating Providers Consult Aetna Dental’s online provider directory, DocFind®, for the most current provider listings. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna Dental or its affiliates. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Not every provider listed in the directory will be accepting new patients. Although Aetna Dental has identified providers who were not accepting patients in our DMO plan as known to Aetna Dental at the time the provider directory was created, the status of a provider’s practice may have changed. For the most current information, please contact the selected provider or Aetna Member Services at the toll-free number on your online ID card, or use our Internet-based provider directory (DocFind) available at www.aetna.com. 29

VSP 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 Rates Employee Only

$9.41

Employee + Spouse

$15.05

Employee + Children

$15.36

Employee Family

$24.77

VSP Provider Network: VSP Signature

Benefit WellVision Exam Prescription Glasses

Frame

Lenses

Lens Enhancements

Contacts (instead of glasses)

Extra Savings

Your Coverage with Other Providers

Description

Copay

Frequency

Your Coverage with a VSP Doctor Focuses on your eyes and overall $10 Every 12 months wellness $30 See frame and lenses  $120 allowance for a wide selection of frames  $140 allowance for featured Included in Prescription Every 24 months Glasses frame brands  20% savings on the amount over your allowance  Single vision, lined bifocal, and lined trifocal lenses Included in Prescription Every 12 months Glasses  Polycarbonate lenses for dependent children  Standard progressive lenses  Premium progressive lenses $50  Custom progressive lenses $80 - $90 Every 12 months  Average savings of 35-40% on $120 - $160 other lens enhancements  $120 allowance for contacts; copay does not apply Up to $60 Every 12 months  Contact lens exam (fitting and evaluation) Glasses and Sunglasses  Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.  30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening  No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction  Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities  After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor $9.41 Member only | $15.05 Member + 1 | $15.36 Member + children | $24.77 Member +family Your Coverage with Out-of-Network Providers

Visit www.vsp.com for details, if you plan to see a provider other than a VSP doctor. Lined Trifocal Lenses......up to Exam..........................up to $50 Single Vision Lenses…….up to $50 Contacts.....................up to $105 $100 Progressive Lenses.........up to Frame........................up to $70 Lined Bifocal Lenses......up to $75 $75 VSP guarantees coverage from VSP doctors only. Coverage information is subject to change. In the event of a conﬂict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

RELIANCE STANDARD 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.

Disability Coverage

Contribution Requirements

Disability income protection insurance provides a benefit for “long term” disability resulting from a covered injury or sickness. Benefits begin at the end of the elimination period and continue while you are disabled up to the maximum benefit duration.

Coverage is 100% employee paid.

Rates See rates on the following pages.

Features

Eligibility Each active full time employee working 20 or more hours per week.

  

Benefit Amount



You may elect a monthly benefit in increments of $100, from a minimum of $200 up to a maximum benefit of $7,500 per month, not to exceed 60% of your covered earnings (rounded to the next lower increment).

    

Elimination Period Option of: 14 consecutive days of total disability 30 consecutive days of total disability 60 consecutive days of total disability 90 consecutive days of total disability 180 consecutive days of total disability *If you are hospital confined as an inpatient because of your disability and have selected an elimination period of 30 days or less, benefits begin immediately. Inpatient means an individual who is physically confined for an overnight stay, as a registered bed patient in a hospital or institution, as defined in the policy or plan.

Maximum Benefit Duration Benefits will not extend beyond the longer of: Social Security Normal Retirement Age or Duration of Benefits below: Age at Disablement Duration of Benefits 61 or less 62

To age 65 3 1/2 years

3 years

2 1/2 years

2 years

1 3/4 years

1 1/2 years

1 1/4 years

69 or more

1 year

Limited Benefit Period for Other Specific Conditions – 24 months Mental/Nervous Illness Limitation – 24 month out-patient Own Occupation Coverage – 24 months Pre-Existing Condition Limitation – 3/12 Residual and Partial Disability Specific Indemnity Benefit Substance Abuse Limitation – 24 months Survivor Benefit – 3 months Work Incentive & Child Care provisions

Value Added Services 

Employee Assistance Program

Exclusions Benefits will not be payable for any disability caused by: an intentionally self-inflicted injury; an act of war (declared or undeclared); commission of a felony; injury or sickness occurring while confined in any penal or correctional institution. For a comprehensive list of exclusions, limitations, and any applicable benefit offsets, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits. This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS-6564, et al.

Disability Scheduled Benefit: Each eligible employee may elect an amount of insurance, in increments of $100 from a minimum of $200 to a maximum of $7,500 per month up to 67% of covered earnings. You may select any benefit amount from $200 up to your maximum monthly benefit. Locate your monthly earnings to determine your maximum monthly benefit amount. If your covered month earnings fall between ranges, the lesser benefit amount will apply.

Monthly Premiums Min. Annual Earnings

Min. Monthly Earnings

$3,600.00 $5,400.00 $7,200.00 $9,000.00 $10,800.00 $12,600.00 $14,400.00 $16,200.00 $18,000.00 $19,800.00 $21,600.00 $23,400.00 $25,200.00 $27,000.00 $28,800.00 $30,600.00 $32,400.00 $34,200.00 $36,000.00 $37,800.00 $39,600.00 $41,400.00 $43,200.00 $45,000.00 $46,800.00 $48,600.00 $50,400.00 $52,200.00 $54,000.00 $55,800.00 $57,600.00 $59,400.00 $61,200.00 $63,000.00 $64,800.00 $66,600.00 $68,400.00 $70,200.00 $72,000.00 $73,800.00 $75,600.00 $77,400.00 $79,200.00

$300.00 $450.00 $600.00 $750.00 $900.00 $1,050.00 $1,200.00 $1,350.00 $1,500.00 $1,650.00 $1,800.00 $1,950.00 $2,100.00 $2,250.00 $2,400.00 $2,550.00 $2,700.00 $2,850.00 $3,000.00 $3,150.00 $3,300.00 $3,450.00 $3,600.00 $3,750.00 $3,900.00 $4,050.00 $4,200.00 $4,350.00 $4,500.00 $4,650.00 $4,800.00 $4,950.00 $5,100.00 $5,250.00 $5,400.00 $5,550.00 $5,700.00 $5,850.00 $6,000.00 $6,150.00 $6,300.00 $6,450.00 $6,600.00

Maximum Monthly Benefit $200.00 $300.00 $400.00 $500.00 $600.00 $700.00 $800.00 $900.00 $1,000.00 $1,100.00 $1,200.00 $1,300.00 $1,400.00 $1,500.00 $1,600.00 $1,700.00 $1,800.00 $1,900.00 $2,000.00 $2,100.00 $2,200.00 $2,300.00 $2,400.00 $2,500.00 $2,600.00 $2,700.00 $2,800.00 $2,900.00 $3,000.00 $3,100.00 $3,200.00 $3,300.00 $3,400.00 $3,500.00 $3,600.00 $3,700.00 $3,800.00 $3,900.00 $4,000.00 $4,100.00 $4,200.00 $4,300.00 $4,400.00

Option 1 14 day EP

Option 2 30 day EP

Option 3 60 day EP

Option 4 90 day EP

Option 5 180 day EP

$5.30 $7.95 $10.60 $13.25 $15.90 $18.55 $21.20 $23.85 $26.50 $29.15 $31.80 $34.45 $37.10 $39.75 $42.40 $45.05 $47.70 $50.35 $53.00 $55.65 $58.30 $60.95 $63.60 $66.25 $68.90 $71.55 $74.20 $76.85 $79.50 $82.15 $84.80 $87.45 $90.10 $92.75 $95.40 $98.05 $100.70 $103.35 $106.00 $108.65 $111.30 $113.95 $116.60

$4.26 $6.39 $8.52 $10.65 $12.78 $14.91 $17.04 $19.17 $21.30 $23.43 $25.56 $27.69 $29.82 $31.95 $34.08 $36.21 $38.34 $40.47 $42.60 $44.73 $46.86 $48.99 $51.12 $53.25 $55.38 $57.51 $59.64 $61.77 $63.90 $66.03 $68.16 $70.29 $72.42 $74.55 $76.68 $78.81 $80.94 $83.07 $85.20 $87.33 $89.46 $91.59 $93.72

$3.62 $5.43 $7.24 $9.05 $10.86 $12.67 $14.48 $16.29 $18.10 $19.91 $21.72 $23.53 $25.34 $27.15 $28.96 $30.77 $32.58 $34.39 $36.20 $38.01 $39.82 $41.63 $43.44 $45.25 $47.06 $48.87 $50.68 $52.49 $54.30 $56.11 $57.92 $59.73 $61.54 $63.35 $65.16 $66.97 $68.78 $70.59 $72.40 $74.21 $76.02 $77.83 $79.64

$3.04 $4.56 $6.08 $7.60 $9.12 $10.64 $12.16 $13.68 $15.20 $16.72 $18.24 $19.76 $21.28 $22.80 $24.32 $25.84 $27.36 $28.88 $30.40 $31.92 $33.44 $34.96 $36.48 $38.00 $39.52 $41.04 $42.56 $44.08 $45.60 $47.12 $48.64 $50.16 $51.68 $53.20 $54.72 $56.24 $57.76 $59.28 $60.80 $62.32 $63.84 $65.36 $66.88

$2.28 $3.42 $4.56 $5.70 $6.84 $7.98 $9.12 $10.26 $11.40 $12.54 $13.68 $14.82 $15.96 $17.10 $18.24 $19.38 $20.52 $21.66 $22.80 $23.94 $25.08 $26.22 $27.36 $28.50 $29.64 $30.78 $31.92 $33.06 $34.20 $35.34 $36.48 $37.62 $38.76 $39.90 $41.04 $42.18 $43.32 $44.46 $45.60 $46.74 $47.88 $49.02 $50.16

Disability Monthly Premiums Min. Annual Earnings

Min. Monthly Earnings

Maximum Monthly Benefit

Option 1 14 day EP

Option 2 30 day EP

Option 3 60 day EP

Option 4 90 day EP

Option 5 180 day EP

$81,000.00 $82,800.00 $84,600.00 $86,400.00 $88,200.00 $90,000.00 $91,800.00 $93,600.00 $95,400.00 $97,200.00 $99,000.00 $100,800.00 $102,600.00 $104,400.00 $106,200.00 $108,000.00 $109,800.00 $111,600.00 $113,400.00 $115,200.00 $117,000.00 $118,800.00 $120,600.00 $122,400.00 $124,200.00 $126,000.00 $127,800.00 $129,600.00 $131,400.00 $133,200.00 $135,000.00

$6,750.00 $6,900.00 $7,050.00 $7,200.00 $7,350.00 $7,500.00 $7,650.00 $7,800.00 $7,950.00 $8,100.00 $8,250.00 $8,400.00 $8,550.00 $8,700.00 $8,850.00 $9,000.00 $9,150.00 $9,300.00 $9,450.00 $9,600.00 $9,750.00 $9,900.00 $10,050.00 $10,200.00 $10,350.00 $10,500.00 $10,650.00 $10,800.00 $10,950.00 $11,100.00 $11,250.00

$4,500.00 $4,600.00 $4,700.00 $4,800.00 $4,900.00 $5,000.00 $5,100.00 $5,200.00 $5,300.00 $5,400.00 $5,500.00 $5,600.00 $5,700.00 $5,800.00 $5,900.00 $6,000.00 $6,100.00 $6,200.00 $6,300.00 $6,400.00 $6,500.00 $6,600.00 $6,700.00 $6,800.00 $6,900.00 $7,000.00 $7,100.00 $7,200.00 $7,300.00 $7,400.00 $7,500.00

$119.25 $121.90 $124.55 $127.20 $129.85 $132.50 $135.15 $137.80 $140.45 $143.10 $145.75 $148.40 $151.05 $153.70 $156.35 $159.00 $161.65 $164.30 $166.95 $169.60 $172.25 $174.90 $177.55 $180.20 $182.85 $185.50 $188.15 $190.80 $193.45 $196.10 $198.75

$95.85 $97.98 $100.11 $102.24 $104.37 $106.50 $108.63 $110.76 $112.89 $115.02 $117.15 $119.28 $121.41 $123.54 $125.67 $127.80 $129.93 $132.06 $134.19 $136.32 $138.45 $140.58 $142.71 $144.84 $146.97 $149.10 $151.23 $153.36 $155.49 $157.62 $159.75

$81.45 $83.26 $85.07 $86.88 $88.69 $90.50 $92.31 $94.12 $95.93 $97.74 $99.55 $101.36 $103.17 $104.98 $106.79 $108.60 $110.41 $112.22 $114.03 $115.84 $117.65 $119.46 $121.27 $123.08 $124.89 $126.70 $128.51 $130.32 $132.13 $133.94 $135.75

$68.40 $69.92 $71.44 $72.96 $74.48 $76.00 $77.52 $79.04 $80.56 $82.08 $83.60 $85.12 $86.64 $88.16 $89.68 $91.20 $92.72 $94.24 $95.76 $97.28 $98.80 $100.32 $101.84 $103.36 $104.88 $106.40 $107.92 $109.44 $110.96 $112.48 $114.00

$51.30 $52.44 $53.58 $54.72 $55.86 $57.00 $58.14 $59.28 $60.42 $61.56 $62.70 $63.84 $64.98 $66.12 $67.26 $68.40 $69.54 $70.68 $71.82 $72.96 $74.10 $75.24 $76.38 $77.52 $78.66 $79.80 $80.94 $82.08 $83.22 $84.36 $85.50

LOYAL AMERICAN

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.

Cancer ADDITIONAL BENEFIT AMOUNTS

LEVEL A Maximum

LEVEL B Maximum

ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, ﬂexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

$50 $50 Per Calendar Per Calendar Year Year

Additional Benefit

$100 We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test Per Calendar Year for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate. FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule. If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and onehalf times the First Occurrence benefit amount shown on the Certificate Schedule.

$2,000 Once per Lifetime $3,000 Once per Lifetime

$100 Per Calendar Year

$2,000 Once per Lifetime $3,000 Once per Lifetime

ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045) We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental $7,500 Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be Per Calendar for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar Year year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.

SURGICAL BENEFIT RIDER (form LG-6048) Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.

Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.

$10,000 Per Calendar Year

$5,000 Procedure Maximum

$1,250 Procedure Maximum

$4,500 Procedure Maximum

Breast Reconstruction With transverse rectus adominis myocutaneous ﬂap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.

Skin Cancer Surgery Expense We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is Per Procedure Per Procedure payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.

Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.

Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.

$200 Per Day

$400 Per Day

$400/ $800 Per Day

Cancer Additional Benefits Amounts SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. Covers These 38 Specified Diseases Addison’s Disease Amyotrophic Lateral Sclerosis Botulism Bovine Spongiform Encephalopathy Budd-Chiari Syndrome Cystic Fibrosis Diptheria Encephalitis Epilepsy Hansen’s Disease Histoplasmosis Legionnaire’s Disease Lyme Disease

Lupus Erythematosus Malaria Meningitis Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Neimann-Pick Disease Osteomyelitis Poliomyelitis Q Fever Rabies Reye’s Syndrome Rheumatic Fever

Rocky Mountain Spotted Fever Sickle Cell Anemia Tay-Sachs Disease Tetanus Toxic Epidermal Necrolysis Tuberculosis Tularemia Typhoid Fever Undulant Fever West Nile Virus Whipple’s Disease Whooping Cough

Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more.

Monthly Rates

Employee

Single Parent

Family

Base Plan A

$21.26

$25.97

$35.84

Base Plan B

$23.17

$28.20

$38.99

Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047) Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.

$1,000 Per Day

Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.

$2,000 Per Day

Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.

$500 Per Day

*Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner. THIS IS A LIMITED RIDER.

Monthly Rates

Employee

Single Parent

Family

Base Plan A

$25.90

$32.36

$44.64

Base Plan B

$27.82

$34.59

$47.79

ALLSTATE

Critical Illness

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

Critical Illness Benefits Base Policy Initial Critical Illness Benefits Heart Attack Stroke

Major Organ Transplant Waiver of Premium End Stage Renal Failure Coronary Artery Bypass Surgery

Second Event Benefit Initial Critical Illness

Supplemental Critical Illness Benefits II Benign Brain Tumor Paralysis Coma Complete Blindness Wellness (Pays annually when one of 23 screening exams is performed) Biopsy for skin cancer Blood test for triglycerides Bone Marrow Testing CA15-3, CA125, CEA and PSA (Blood tests)1 Chest X-ray Colonoscopy Doppler screenings or carotids and peripheral vascular disease Echocardiogram EKG (Electrocardiogram) Flexible Sigmoidoscopy

Complete Loss of Hearing $154.50 $222.50

Hemoccult stool analysis HPV Vaccination (Human Papillomavirus) Lipid panel (Total cholesterol count) Mammography (Including Breast Ultrasound) Pap Smear (ThinPrep Pap Test included) Serum Protein Electrophoresis (Myeloma test) Stress test on bike or treadmill Thermography Ultrasound screening (abdominal aortic aneurysms)

Breast, ovarian, colon and prostate cancer. *Employee only.

Benefit Amounts

Covered Dependents Receive 50% of Your Benefit Amount

INITIAL CRITICAL ILLNESS BENEFITS*

PLAN 1

PLAN2

SECOND EVENT BENEFIT*

PLAN 1 PLAN2 Yes

Heart Attack (100%)

$10,000

$20,000

Second Event Initial Critical Illness Benefit (same amount as Initial Critical Illness)

Stroke (100%)

$10,000

$20,000

SUPPLEMENTAL CRITICAL ILLNESS BENEFITS II* PLAN 1 PLAN 2

Coronary Artery Bypass Surgery (25%)

$2,500

$5,000

Major Organ Transplant (100%)

$10,000

$20,000

End Stage Renal Failure (100%)

$10,000

$20,000

Waiver of Premium (employee only)

Yes

Advanced Alzheimer's Disease (25%) Advanced Parkinsonâ&#x20AC;&#x2122;s Disease (25%) Benign Brain Tumor (100%) Coma (100%) Complete Blindness (100%) Paralysis (100%)

$2,500 $2,500 $10,000 $10,000 $10,000 $10,000

$5,000 $20,000 $20,000 $20,000 $20,000 $20,000

ADDITIONAL BENEFIT

PLAN 1 PLAN 2

Wellness Benefit (per year)

$50

Monthly Premiums PLAN 1

PLAN 1

PLAN 2

$10,000 Basic Benefit Amount Non-tobacco

$10,000 Basic Benefit Amount Tobacco

$10,000 Basic Benefit Amount Non-tobacco

$10,000 Basic Benefit Amount Tobacco

AGES

EE, EE + CH

EE +SP, F

AGES

EE, EE + CH

18-29

$2.74

$4.73

18-29

30-39

$4.83

$7.87

30-39

40-49

$8.13

$12.81

50-59

$14.46

$22.32

60-63 64+

60-63

$24.42

$37.26

64+

$34.22

$51.95

EE +SP, F

AGES

EE, EE + CH

$3.54

$5.93

18-29

$4.23

$6.97

18-29

$2.74

$9.38

$6.84

$10.88

30-39

$8.42

$13.25

30-39

$4.83

$19.27

40-49

$13.27

$20.53

40-49

$15.02

$23.15

40-49

$8.13

$38.57

50-59

$22.97

$35.08

50-59

$27.69

$42.15

50-59

$14.46

$67.65

$39.87 $56.74

$60.44 $85.74

60-63

$47.60

$72.02

60-63

$24.42

$118.37

64+

$67.18

$101.40

64+

$34.22

$168.97

EE +SP, F

AGES

EE, EE + CH

EE+ Employee; EE+SP + Employee + Spouse; EE+CH + Employee + Child(ren); F = Family

EE +SP, F

AUL A ONEAMERICA COMPANY

Life and AD&D

YOUR BENEFITS PACKAGE

About this Benefit Life insurance provides a cash death benefit to your beneficiary upon your death. 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 wellbeing of your family. If you are covered, you may apply for coverage on your spouse and eligible dependent children.

DID YOU KNOW? Experts recommend at least

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

Life and AD&D Basic Life a with AD&D

Continuation of Coverage Options:

Lake Worth provides $50,000 of Life with AD&D coverage to all full-time employees at no cost.

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

Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 20 hours per week.

Flexible Choices:

Conversion Since everyone's needs are different, this plan offers flexibility for Should your life insurance coverage, or a portion of it, cease for you to choose a benefit amount that fits your needs and budget. any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you Accidental Death & Dismemberment (AD&D): If approved for this benefit, additional life insurance benefits may are eligible. be payable in the event of an accident which results in death or Accelerated Life Benefit: dismemberment as defined in the contract. If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life Guaranteed Issue Amounts: insurance benefit to use for whatever you choose. This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence Waiver of Premium: If approved, this benefit waives your and your dependents' of Insurability. insurance premium in case you become totally disabled and are Employee Guaranteed Issue Amount $200,000 unable to collect a paycheck. Spouse Guaranteed Issue Amount $50,000 Reductions: Upon reaching certain ages, your original benefit amount will Timely Enrollment: reduce to a percentage as shown in the following schedule. Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

Age:

Reduces To:

65%

50%

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

This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued. 43

Life and AD&D Monthly Payroll Deduction Illustration About your benefit options:    

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

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

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.70

$.80

$.90

$1.50

$2.20

$3.80

$6.40

$8.60

$14.80

$20,000

$1.40

$1.60

$1.80

$3.00

$4.40

$7.60

$12.80

$17.20

$29.60

$30,000

$2.10

$2.40

$2.70

$4.50

$6.60

$11.40

$19.20

$25.80

$44.40

$40,000

$2.80

$3.20

$3.60

$6.00

$8.80

$15.20

$25.60

$34.40

$59.20

$50,000

$3.50

$4.00

$4.50

$7.50

$11.00

$19.00

$32.00

$43.00

$74.00

$70,000

$4.90

$5.60

$6.30

$10.50 $15.40

$26.60

$44.80

$60.20 $103.60 $103.60 $103.60

$90,000

$6.30

$7.20

$8.10

$13.50 $19.80

$34.20

$57.60

$77.40 $133.20 $133.20 $133.20

$100,000

$7.00

$8.00

$9.00

$15.00 $22.00

$38.00

$64.00

$86.00 $148.00 $148.00 $148.00

$150,000

$10.50 $10.50 $10.50 $12.00 $13.50 $22.50 $33.00

$57.00

$96.00 $129.00 $222.00 $222.00 $222.00

$200,000

$14.00 $14.00 $14.00 $16.00 $18.00 $30.00 $44.00

$76.00 $128.00 $172.00 $296.00 $296.00 $296.00

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

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.70

$.80

$.90

$1.50

$2.20

$3.80

$6.40

$8.60

$14.80

$20,000

$1.40

$1.60

$1.80

$3.00

$4.40

$7.60

$12.80

$17.20

$29.60

$30,000

$2.10

$2.40

$2.70

$4.50

$6.60

$11.40

$19.20

$25.80

$44.40

$40,000

$2.80

$3.20

$3.60

$6.00

$8.80

$15.20

$25.60

$34.40

$59.20

$50,000

$3.50

$4.00

$4.50

$7.50

$11.00

$19.00

$32.00

$43.00

$74.00

Life and AD&D CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children)

Option 1:

Child(ren) 6 months to age 26

Child(ren) live birth to 6 months

Monthly Payroll Deduction Life Amount

$10,000

$1,000

$1.50

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance CompanyÂŽ (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.

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 LIFELOCK BASIC

LIFELOCK ULITMATE

IDENTITY GUARD

INFO ARMOUR

IDW PLUS

IDW PLATINUM

INDIVIDUAL PLAN

$7.95/mo

$11.95/mo

FAMILY PLAN

$14,95/mo

$22.95/mo

Basic Identity Monitoring Advanced Identity Monitoring Alternative Monitoring Zero Hour Identity Monitoring Cyber Monitoring Credit Report Monitoring Credit Reports & Scores Lost Wallet Full-Service Identity Restoration NPI Monitoring

True Identity Protection Basic Identity Monitoring: Standard monthly scans of public records databases searching for new information associated with your Social Security Number. Advanced Identity Monitoring: Advanced scans of the National Change of Address (NCOA) database identifies new addresses associated with your personal information.

Credit Reports & Scores (Platinum Plan Only): Access to your credit reports and scores from the three primary credit reporting agencies; Equifax, Experian and TransUnion.

Extended Identity Protection Lost Wallet: Online safe box securely stores credit card, driver license info and more. Includes cancellation and request for new credit cards in the event your wallet or purse is stolen.

Alternative Monitoring: Identity thieves actions are not always immediately detected through mainstream credit and identity monitoring. Today we scan Non-Credit Payday loan databases which provide highinterest, quick cash transactions and require minimal personal information to obtain. We are expanding our fraud detection network to include monitoring Auto Pawn, Buy-Here- Pay Here auto dealers and Rent-To-Own store transactions. This is the most comprehensive alternative credit monitoring in the ID theft protection industry.

Proactive Zero Hour Identity Monitoring: Continuous monitoring from daily scanning of billions of transactions and data points will provide an early warning alerting customers of high risk transactions. Because this system is monitoring in real time you will be able to detect potential fraud as it is happening or immediately after it has happenedat the source- so that our dedicated team can help you stop it in its tracks and prevent the damage that can occur with identity theft. Cyber Monitoring: Scans social networking sites, hacker forums, underground websites and other illicit online sources that buy, sell, and trade personal information including (but not limited to) credit card numbers, password, and SSN.

Full-Service Identity Restoration: A dedicated team of trained in-house Certified Identity Theft Resolution Specialists (CITRS) who work on your behalf to restore your identity by addressing record- keeping and reporting agencies, removing erroneous and fraudulent records that appear in your name. ID Watchdog has a flawless record in restoring victimâ&#x20AC;&#x2122;s identities- and to date we have never failed to completely restore an identity. A benefit of our concierge level service is few costs associated with identity restoration. However, we know peace of mind is important. All our ID Protection Plans include a $1,000,000 expense reimbursement insurance* to cover those rare instances when expenses may arise during a restoration. NPI Monitoring: Monitors National Provider Identifiers (NPI) for healthcare professionals. * Maximum $1 Million reimbursement insurance under a Master Insurance Policy underwritten by American International Group Inc. Please reference ID Watchdog benefits website for claim submission instructions and policy 43 details regarding applicable terms, conditions, and exclusions.

Credit Report Monitoring: Monitors your credit and notifies you when changes such as new accounts, delinquent accounts and other creditrelated information is recorded. Plus plan is single-bureau credit monitoring and Platinum plan is tri-bureau monitoring.

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

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

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

Money withdrawn for medical spending never falls under taxable income.

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an  Not enrolled in Medicare (if an accountholder enrolls in affordable health coverage option that helps you save on Medicare mid-year, catch contributions should be prorated) healthcare expenses. This plan is only available for those who are Authorized Signers who are 55 or older must have their own participating in the Active Care 1-HD medical plan. You may not HSA in order to make the catch-up contribution enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to Monthly Fee: Your account will be charged a monthly fee of participate in the FSA plan if you participate in HSA. Medicare, $1.75, waived with an average daily balance at or above Medicaid, and Tricare participants are not eligible to participate $3,000. in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 

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

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

For a list of sample expenses, please refer to the Lake Worth ISD website at www.mybenefitshub.com/lakeworthisd

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

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

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

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

How an HSA works:



 

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

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

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

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

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

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

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

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

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

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

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

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